The History of Anesthesiology Reprint Series: Volume 23

THE ROVENSTINE LECTURES Part One

PHOTOGRAPHS FOUR STAGES IN THE LIFE OF E. A. ROVENSTINE, M.D., 1895-1960

History of Anesthesiology Reprint Series Volume 23, 1993

The Rovenstine Lectures

The Rovenstine Lectureship was endowed in 1962 by the E. R. Squibb Pharmaceutical Company soon after his untimely death to commemorate the life and lasting contributions to anesthesiology of Emery Andrew Rovenstine. Although a true pioneer, he is more accurately depicted as a second generation anesthesiologist who established the department at New York University - Bellevue Hospital Medical School in 1935. Having come from Indiana, Middle West, as did the other pioneers, he was one of those early trainees in Ralph M. Waters' newly established residency training program at Wisconsin, then to come east. Everyone will agree that in the long run an exemplar and teacher is best remembered in the personas of his disciples. This dictum is amply substantiated by way of the Wisconsin Aqua Alumni Tree, a figurative representation of those who have become chairpersons of academic departments throughout the world. Rovie's branch, a stout outgrowth at the base of the trunk, is a fertile one with ever so many bifurcations. Over the years there have been some 31 Rovenstine lectures which subtly reveal the burgeoning and ramifications of our specialty, perhaps as a pentimen- to of Rovie's aspirations. Originally the lecturers were chosen by the Chairman of the Section on the Annual Meeting, latterly by the President of the ASA. We present here a sampling of those orations which subsequently appeared in the journal, Anesthesiology. More than a few Rovenstine descendants are thus rep­ resented along with an illustrious cohort of other leaders in Anesthesiology. With the enthusiastic approval of B. Raymond Fink, Chairman, and the Com­ mittee on Publications of the Wood Library-Museum,

Leroy D. Vandam, M.D.

History of Anesthesiology Reprint Series Volume 23

The Rovenstine Lectures Selected Papers Parti

1. Papper, E.M. Regional Anesthesia: A Critical Assessment of Its Place in Therapeutics (1966) 2. Dripps, Robert D. The Physician and Society. (1970) 3. Eckenhoff, James E. A Wide-angle View of Anesthesiology. (1977) 4. Vandam, Leroy D. Anesthesiologists as Clinicians. (1979) 5. Hershey, S.G. The Rovenstine Inheritance -A Chain of Leadership. (1982) 6. Keats, Arthur S. Cardiovascular Anesthesia: Perceptions and Perspectives. (1983) 7. Michenfelder, John D. Neuroanesthesia and the Achievement of Profession­ al Respect (1988) 8. Hornbein, Thomas F. Lessons from on High. (1989) 9. Stoelting, Robert K. Clinical Challenges for the Anesthesiologist. (1990)

-1- REGIONAL ANESTHESIA A Critical Assessment of Its Place in Therapeutics by E. M. Papper, M.D. E. A. Rovenstine Memorial Lecture

Introduction

THE subject for the Fifth Annual Rovenstine ogy and to our society. However, it is safe to Memorial Lecture is "Regional Anesthesia—A say that during the last 25 years, he has served Critical Assessment of its Place in Therapeu­ us well on virtually every scientific and edu­ tics." The theme is altogether fitting for the cational committee and board in anesthesiol­ occasion since this problem was of particular ogy, both nationally and internationally. He is interest to Dr. Rovenstine for many years. In Professor and Chairman of the Department of thinking about one who should give this ad­ Anesthesiology at Columbia University and dress, it quickly became apparent that it most recently he has served us as the first Vice would be eminently appropriate to invite one President of our Society and as Principal Con­ of Dr. Rovenstine's most illustrious students; sultant to the National Institute of General our speaker is just such a person. He is also Medical Sciences of the National Institutes of the first anesthesiologist to serve as the Roven­ Health in Washington. It gives me great per­ stine Lecturer. I will not attempt to enu­ sonal pleasure to present the Rovenstine Lec­ merate his many contributions to anesthesiol­ turer for 1966, Dr. Emanuel M. Papper.

Regional Anesthesia A Critical Assessment of Its Place in Therapeutics

E. A. Rovenstine Memorial Lecture

E. M. Papper, M.D*

I FEEL signally honored to have the privilege recent developments in this field. Before of giving the annual Rovenstine Lecture. The doing so, I wish to pay a short tribute to a honor is heightened by both pleasure and hu­ great man, in words which, I hope, will also mility. My years with him were cherished. set the background for the remainder of this The opportunities which he provided for me lecture in his honor and in his memory. are impossible to describe fully and I cannot E. A. Rovenstine was one of the most dis­ express sufficiently my gratitude to him. I tinguished of anesthesiologists of his time. He have undertaken a critical discussion of a sub­ may very well have had a greater influence on ject that was dear to his heart—a field that the development of this specialty than any has always fascinated me as it did him—the other physician because of his versatility as a field of therapeutic and diagnostic nerve blocks. teacher, clinician, and clinical investigator. It is one that I find perplexing now. I wish Born in Atwood, Indiana, in 1895, and edu­ to share these controversial and puzzled views cated at Wabash College and Indiana Uni­ with you, from the perspective of old and versity, Rovenstine came to New York from Wisconsin in 1935 to start the first academic * Professor and Chairman, Department of Anes­ department of anesthesiology in that city. His thesiology, Columbia University College of Physi­ cians and Surgeons, New York City. medical interests were incredibly wide and his Presented at the Annual Meeting of the Ameri­ skills magnificent. He was far ahead of his can Society of Anesthesiologists, Philadelphia, Oc­ tober 5, 1966. time in recognizing the future importance of 1074 Volume 28 E. A. ROVENSTINE MEMORIAL LECTURE Number 6 1075 the physical as well as the biological sciences to anesthesiology. He predicted as early as 1947 that physics, electronics, and even auto­ matic devices would one day have a great impact on clinical anesthetic practice. He had a remarkable interest in the appli­ cation of regional anesthetic procedures to surgical operations. He extended this interest thereafter to the study and therapy of other diseases, many of them painful: hence our dis­ course today. He brought the knowledge of the anesthesiologist in the control of pain to aid in the diagnosis and therapy of many dif­ ferent diseases. His favorite clinical problems for regional block were patients with trigemi­ nal neuralgia, the painful shoulder, and the causalgic states. The pain of cancer interested him to a lesser degree, an irony of sorts in view of his eventual tragic battle with a pros­ tatic cancer which finally took him from us in 1960. His marked curiosity and interest in painful states was a logical development in view of the opportunities that Rovenstine had and uti­ lized to further this particular skill. He was, in fact, almost preoccupied with this aspect of E. A. Rovenstine, M.D. anesthetic care. His interest in this field be­ gan when he met Gaston Labat, the distin­ tedious application necessary in the compila­ guished French surgeon who had turned re­ tion, digestion, and production of material for gional anesthetist. Labat at that time was per­ bookwriting. He preferred to look forward to forming much of the regional anesthesia in new things rather than write about the old— Bellevue Hospital and also consulted at The even though he wrote easily and with a grace Presbyterian Hospital in New York. Roven­ that had ever so small a touch of the flowery. stine also became a close friend of another However, he did secure from Madame Labat surgeon interested in regional anesthesia who a large collection of drawings and plates which remained a practicing surgeon, Dr. Hippolyte were to be used for a subsequent edition of Wertheim. The welding of the superb ana­ the book. Some of these magnificent drawings tomical knowledge of Wertheim and the amaz­ have, fortunately, not been lost, and were uti­ ing technical skill of Labat with the inquisi­ lized by Vincent J. Collins in his textbooks tive scholarly and clinical knowledge of Rov­ on anesthesiology. Many drawings and plates enstine, resulted in a cohesive direct attack were also commissioned and drawn by a now upon the problems of diagnosis, prognosis and well-known artist, a friend of mine from World therapy of diverse abnormalities which had in War II days, Carroll N. Jones, Jr.; some of common only the transmission of impulses, these have also appeared in Collins' works. painful or otherwise, over nerve pathways. Rovenstine's interest in this subject carried Rovenstine's interest in therapeutic nerve him even further. He instituted courses in block carried him to the point where he in­ cadaver dissection in regional anesthesia which tended to write, with Madame Labat's ap­ were available to the residents of the Bellevue proval, a second edition of Labat's classic book Hospital Department and were also highly on Regional Anesthesia. He never produced popular with anesthesiologists from other parts this work because he disliked the discipline of of the country. Among the students in these EMANUEL M. PAPPER Anesthesiology 1076 Nov.-Dec. 1967

TABLE 1. Summary of Recent Experience at The some of the questions that need to be asked. Presbyterian Hospital with Nerve Blocks It is important to state at this point that one of the tacit assumptions always made by the Diagnostic and Therapeutic Nerve Blocks writers in the field is that the simple interrup­ Period 4.5 years tion of a conducting pathway is destined by (1962-1966) that very act to prevent noxious, harmful or painful impulses from reaching the central Total 1336 nervous system, and therefore to alleviate dis­ Diagnostic & comfort. This is not necessarily so, as we shall Prognostic 41 % Therapeutic 59% see, for a multitude of variables impinge on the therapeutic value of nerve block.

Recent Clinical Experiences at the Co­ early courses were Doctors Dripps, Lamont, Collins and Gonzalez—to name only a few lumbia-Presbyterian Medical Center individuals who subsequently achieved promi­ Table 1 summarizes some of the recent ex­ nence. Rovenstine taught much of the didac­ periences at The Presbyterian Hospital. It tic part of this course and was a demonstrator will be noted that of the total number of pro­ of therapeutic nerve block on patients for the cedures, something over 1,300 performed in students. He was always at his best when he the last 4V2 years, approximately 60 per cent could demonstrate before and teach a group were done for therapeutic purposes and some of postgraduate students. 40 per cent for diagnostic purposes. The diagnostic aspect of regional anesthesia is very Rovenstine's Attitude Toward the often neglected. Its role here is extraordi­ Control of Pain narily useful and critically important in se­ lecting those patients in whom surgery or psy­ In a paper in which I had the privilege of chiatry may offer definitive help. In 1965, being co-author, published in 1948, we de­ Jones of The Mayo Clinic suggested that neu­ scribed the obligation of the anesthesiologist rosurgery may be the treatment for certain and his opportunity to participate in the thera­ painful states, and that diagnostic nerve block peutics of pain, in this way: "Events in the may be useful in indicating in which of these changing medical world have made it impera­ tive that our functions be broadened and we states it may be applied; e.g., pain over the accept the challenge of pain occurring outside distribution of a peripheral nerve may be bet­ the surgical amphitheater. Such a concept ter controlled by neurectomy; pain over the fully justifies an anesthesia clinic on the ther­ distribution of a spinal nerve may be better 1 apy of pain." "Pain, whose unheeded and fa­ controlled by rhizotomy. The latter preserves miliar speech is howling and keen, shrieks day motor function and can destroy the sensory after day."—as Shelley put it. function of a nerve; it is therefore more selec­ tive than nerve block. Pain over an extensive area can be best controlled by chordotomy General Remarks as Justification for Con­ which may be attended by fewer complica­ sidering a Critical Assessment of the tions than multiple injections of nerves. Per­ Place of Regional Anesthesia haps just as important but almost never men­ in Therapeutics tioned is that nerve block can sort out those One of the underlying problems in the as­ patients who would be poorly managed by sessment of nerve block is that the literature either surgery or destructive nerve block with is prolific in praising and recommending the phenol or alcohol. value of nerve blocks in an uncritical way, and For instance, one of the procedures that we does not take fully into account some of the have found valuable even in pain resulting problems that have to be considered. We from cancer is to do a "dummy" or placebo shall concern ourselves with a detailed con­ nerve block with saline, in order to evaluate sideration of a few of the problems and raise the effect of psychological factors in the gene- Volume 28 E. A. ROVENSTINE MEMORIAL LECTURE Number 6 1077 sis of pain. The placebo block connotes a TABLE 2. Summary of Patients Given Nerve Blocks potent procedure to a patient, i.e., the inser­ at The Presbyterian Hospital in Recent Years tion of needles and the implied promise of re­ Diagnostic and Therapeutic lief from suffering. The placebo effect can be Nerve Blocks great, and it must be evaluated for at least Period 4.5 years two reasons. The decision to destroy a nerve (1962-1966) requires that one be absolutely certain that the nerve must be destroyed in order to re­ Inpatients 1039 lieve the symptom, otherwise the patient has Outpatients 297 a great disservice rendered him. The under­ Total 1336 standing of pain or the disturbed neurophysi- ological process implies that the removal of nerve impulses is critical to the alteration of due to a variety of factors; one is lack of the syndrome. In our hands, the placebo ef­ understanding of the mechanism of pain. For fect of saline block has been important in instance, the basic assumption that the de­ something over 30 per cent of all patients struction of a neuronal carrier of impulses to studied, regardless of the source of pain. the central nervous system is the way to at­ The obvious conclusion from such experi­ tack pain could be wrong or at least only par­ ence is that a block with saline should be done tially adequate for some disorders. The anes­ in at least the doubtful cases. The incidence thesiologist must understand and do something of pain relief after a block with local anes­ about unraveling the mechanism of pain in thetic must clearly exceed 30 per cent in or­ order to evaluate his participation as a der to be acceptable as a useful clinical pro­ therapist. cedure. Therefore, as a practical measure, I A definition of pain is extraordinarily diffi­ would recommend that a block with saline be cult to phrase because it basically is a subjec­ instituted after a successful block with an tive sensation which can properly be experi­ aqueous solution of a local anesthetic, before enced only by the person who has it, and not making a definitive judgment as to the ulti­ all people experience pain. It has been stated mate therapeutic procedure to be used if de­ that pain experience is the sensation derived struction of nerve is involved. from noxious impulses traveling specific path­ At The Presbyterian Hospital in the last ways. Such phenomena may be followed by AV2 years the largest number of patients were the familiar and predictable feeling states. inpatients, and approximately little more than This "specific" theory has been known as the Va were outpatients (Table 2). It is also of physiological theory of pain. It certainly does interest that over this period when diagnostic not explain all the phenomena of pain. For and therapeutic nerve blocks were in relative instance, the impulse which causes a feeling disfavor and on the decline, there were none­ of pain may certainly not be noxious. A light theless still nearly 300 blocks performed, on brush of the skin in a patient with causalgia the average, per year. These comprised 1.1 can cause the most unholy of terrors. The per cent of all anesthetic procedures done by pathways are certainly far from specific—a the Department of Anesthesiology and some concept implicit in this theory. 7 per cent of all regional anesthetic proce­ Also, the concept that there is a specific sen­ dures. Prior to 1962, more diagnostic and sory unit consisting of specific free branched therapeutic blocks were performed for more naked nerve endings in the periphery, espe­ diseases than is true at the present. Some cially in skin, which are connected to a single reasons for this decline will be discussed. cell in the dorsal root ganglion, is clearly naive in the light of recent studies. The Mechanism of Pain Another objection to the "specific" concept The uncertainties and disquietudes about is that there are patients who are congenitally the role of regional anesthesia in clinical con­ insensitive to pain and as far as one can tell ditions, especially in painful states, may be have absolutely normally conductive neural EMANUEL M. PAPPER Anesthesiology 1078 Nov-Dec. 1967

gia and other states were propagated. This theory has also been shown to be inadequate. Neither of these theories adequately ex­ plains all aspects of the mechanism of pain. A new theory of the mechanism has just been proposed; the so-called gateway theory, by Melzack and Wall.3 Insufficient time has elapsed to interpret the impact of the Wall theory on the comprehension of the pain proc­ ess. I recommend that the studies of these investigators be watched with interest as they appear.

OF The Problem of Accuracy in Nerve Block VERTEBRA Even though one assumes that there is suf­ ficient knowledge about which nerves are to be blocked, diagnostically or therapeutically, FIG. 1. Technique or thoracic and lumbar somatic the question arises as to how accurately one block as described by Shaw.4 can place a needle near the nerve to be blocked, through the unbroken skin. It goes pathways. There are the classic papers of without saying that a precise knowledge of Jewesbury 2 and others who describe this find­ anatomy is extremely important so that the ing. In fact, one went so far as to state that regional anesthesiologist can visualize the di­ pain was not an essential biological adjustment rection of the thrust of his needle. He should and cited three boys, brothers, with insensitive have a three dimensional sense as to where skins who plagued their mother by exhibition- needles should go in relation to bony land­ istic self-torture. marks and soft tissues. There is no substitu­ tion for acquiring this skill in repeated cadaver The Spatial or Psychological Theory dissection. of Pain However, even with this knowledge, there This concept contends that pain is an inter­ are certain points about the accuracy of needle pretive rather than a specific phenomenon. placement that are useful. One should not be The proponents of this theory believed that, bound by tradition in the technical approaches neurophysiologically, a change in the intensity to nerve block. For instance, paravertebral of the stimulus may progress through sensa­ thoracic and lumbar somatic block are still tions of touch, heat, and pain, all carried over performed by the method of Labat or the the same neural pathways. In certain diseases modifications of Rovenstine; these methods are or abnormal states touch may be interpreted not wholly satisfactory. A more accurate as pain. Examples of these conditions are method for these blocks has been described causalgia, spinal anesthesia and nerve block anesthesia for operation. The past experience TABLE 3. Method for Proper Placement of Needle of the patient also enters into the interpreta­ —Relation Between the Voltage Required to Stimu­ tion of the phenomenon. late and the Distance from the Nerve Adding immeasurably to these concepts is the suggestion that an internuncial group of Distance-Voltage Relation neurones can become hypersensitive because Touching nerve 1 to 2 volts of repetitive bombardment at different rates 3 mm. 3 to 5 volts of speed through short and long fibers, and G mm. 10 volts 8 mm. 15 to 20 volts become hyperconductors, as it were, of nor­ Over 8 mm. No stimulation at mal stimuli. This was the so-called "irritable higher voltages focus" by which the persistent pain of causal­ Volume 28 E. A. ROVENSTINE MEMORIAL LECTURE Number 6 1079 by Shaw." The technique has, unfortunately, not gained popularity, probably owing to lack of awareness of its description. This approach is shown in figure 1, not only as a good method in itself, but an illustration of the fact that technical proficiency in nerve block has not died with the old masters and that a renewed study of applied neuroanatomy will be reward­ ing to those interested in this field. The proper placement of the needle requires as much assistance as can be obtained. One of the ways in which this has been done was advocated by Greenblatt and Denson in 1962.5 FIG. 2. Rasilar view of the skull, retouched This method involves the use of an electrical with barium, demonstrating the openings of the stimulator to locate the peripheral nerves. foramina ovale. These authors found a relation between the voltage required to stimulate and the distance from the nerve (table 3). If nerve destruc­ tion is contemplated, obviously the closer the needle is to the nerve the greater the likeli­ hood of success. Our experience with the electrical stimulator has been good in those procedures wherein precise location of nerves is difficult, e.g., obturator nerve block. It is not the complete answer to those blocks which must be done with destructive agents, al­ though it is certainly helpful. Another method of precise location of the place of injection is by means of radiographic control. By and large the anesthesiologist will do well to associate himself with a skilled per­ son in radiology, preferably one with an in­ FIG. 3. Lateral view of the skull employing radiographic control in the performance of man­ terest in neuroradiology. Figures 2 and 3 are dibular branch of the fifth nerve. from studies done in collaboration with Doctor Gordon Potts of the Department of Radiology with block with lidocaine (Xylocaine) and at Columbia University. Figure 2 is a basilar view of the skull which has been retouched subsequently with saline. This figure demon­ with barium to demonstrate the openings of strates the value of radiography in locating the the foramina ovale. This approach is most exit of the nerve from the foramen ovale. useful for the proper performance of gasserian ganglion block. A lateral view (not shown) The Problem of Anesthetic Agents is also necessary. Figure 3 is a view em­ to be Used ploying radiographic control in the perform­ It is apparent that the anesthesiologist must ance of block of the mandibular branch of the have a clear concept of the materials to be fifth nerve. This needle at the foramen ovale used in order to achieve diagnosis and ade­ is blurry and perhaps should have been re­ quate results with regional anesthetic methods. touched for greater clarity. The patient was If the goal is that of nerve destruction he must an intelligent, middle-aged woman who had a recognize the fact that the commonly used classical tic douloureux of the third division neurolytic agents, absolute alcohol and phenol, of the fifth nerve. The true nature of the produce a relatively small area of destruction, pain was proven on two separate occasions approximately a few millimeters for one ml. 1080 EMANUEL M. PAPPER Anesthesiology Nov.-Dec. 1967 of the substance used. He must also recog­ Other physiological changes also influence nize that there will be some degree of neural nerve conduction. For example, carbon diox­ irritation produced in a certain number of pa­ ide has a depressant effect upon nerve conduc­ tients. The incidence of neuropathy with tion. In order to evaluate the effects on heightened pain patterns is variably reported, nerves of aqueous solutions of anesthetics for but in our experience affects nearly 10 per diagnosis and therapy, such considerations cent of those patients treated locally with ab­ must be borne in mind. It is not sufficient to solute alcohol. The neuropathy is believed to say that patients vary so much that patient be due to partial destruction of neural fibers. variability will account for the changes. In addition, the anesthesiologist must be When one looks at the experimental data aware (even if he does not use them) that and thinks of synthesis of new local anesthetic for destruction of nerves such modalities as agents which may be time controlled for vari­ ultrasound, radioactive materials (e.g., radio ous purposes, it appears as though the most Strontium-Yttrium in a dose range of 50 milli- exciting advance in recent years in the chem­ curies or so) can also be used for nerve de­ istry of local anesthetics may be in unraveling struction via properly placed needles. the complicated structure of tetrodotoxin. It In those circumstances where he intends is a fascinating material in many ways includ­ to use aqueous solutions of anesthetics for ing the fact that it has a very low lipid solu­ therapeutic effect or diagnostic purposes, the bility. Classically, it has always been stated anesthesiologist should understand something that effective local anesthetics must have a of the mechanism of action of these drugs in high lipid solubility. Chemists are attempting order to predict the result. Without such to synthesize tetrodotoxin and to modify it understanding the discovery of new drugs is chemically in order to produce local anesthetics subject to or doomed to failure or delay. with the desired spectrum of effects. To summarize the essentials—it is now con­ ceded that aqueous local anesthetics work by Total Management of the Patient interference with the uptake of sodium by the In addition to matters of technical skill and nerve. This mechanism has been clarified by chemical solutions, the total management of a recent studies on tetrodotoxin, a potent poison patient in need of therapeutic regional anes­ extracted from the tissues of the puffer fish. thesia is of considerable importance. The This substance blocks only uptake of sodium physician must choose his patients, must be and is probably the most potent local anesthetic aware of the natural history of the diseases agent known since it produces a permanent that he is concerned with, and must recognize state of non-conduction. Most of the conven­ the role that he plays as a physician in the tional local anesthetics block sodium uptake overall management of a patient who requires by nerve cells, and appear, in addition, to exert regional anesthetic procedures. In the light an influence on potassium flux. However, this of these comments, it would serve us well to mechanism is not uniformly agreed upon. The consider some specific problems that have work of Ritchie at The Albert Einstein College been dealt with over the years with regional of Medicine suggests that the basic form of anesthetic methods. the local anesthetic is necessary for penetration of the nerve sheath, but that the activity at The Treatment of Patients with Cancer the nerve membrane depends upon ioniza­ Much has been written on this subject and tion.6 Ritchie's observations have been con­ it is well to examine some of the results ob­ firmed with employment of the type of Ring­ tained so that the anesthesiologist will be pro­ er's solution that he uses. However, if the vided with information with which to compare Ringer's solution is of the more conventional his own experience. type, the classic view that the basic form of The female genitourinary tract, the breast, the local anesthetic is more active is supported the pelvis and the lower gastrointestinal tract regardless of whether one is dealing with a account for over 50 per cent of the pain re­ myelinated or unmyelinated nerve. sulting from malignant disease (table 4). Volume 28 E. A. ROVENSTINE MEMORIAL LECTURE Number 6 1081

TABLE 4. Source of Cancer Causing Pain in Women TABLE 5. Usual Therapy for Cancer Pain from a History of 714 Patients Genitourinary tract 150^1 Breast and pelvis 112 V Over 50% Patients Lower gastrointestinal tract 124J Nerve block 21 Others 328 7 Narcotics 242 (Perese 1961 ) Palliative surgery 106 Radiations 100 Other methods 45 7 Most patients fall into the middle-age group. (Perese 1961 ) The large majority of patients have had pain somewhat less than six months when they present themselves for treatment. TABLE 6. Systemic Therapy for Cancer Pain in 714 Patients at Presbyterian Hospital In the normal course of events, palliative surgery, radiation and narcotics are the most Patients commonly used procedures in the therapy of Nerve block 14 cancer pain (table 5). When cancer pain is Cordotomy 113 systematically attacked by a group of physi­ Narcotics 113 cians interested in the problem, nerve block, Radiation 53 Other methods 293 chorodotomy and narcotics became the main­ stays of treatment (table 6). This is not sur­ prising in view of the fact that the large ma­ TABLE 7. Results of Subarachnoid Alcohol jority of patients have pain in those nerve Block in 106 Patients tracts amenable to destruction either by re­ gional anesthetics or by operation, i.e., the Complete pain relief 50% female genitourinary tract, the breast, the Partial pain relief 33% pelvis. This is also a commentary on how much more important nerve block could be­ come in planned therapy. creas, has been disappointing. We have done Nerve block therapy for cancer patients, ac­ very much better for the relief of pain in those cording to Bonica, yields approximately 60 per patients who have extension to skeletal areas cent complete relief of pain and nearly 15 that are amenable to segmental paravertebral per cent failures, with intermediary effects in block according to the method of Shaw, and the others.8 These results should be evalu­ where life expectancy would probably not ex­ ated in accordance with the now well estab­ ceed six months. lished placebo effect, that is, a 30 per cent We have also had success in treating cancer "cure" rate for any therapeutic measure even pain in those areas which are within the in cancer pain. clearly defined limits of a peripheral nerve, The use of subarachnoid alcohol block has e.g., a cranial nerve, especially a branch of the waxed and waned over the years. The results fifth nerve. Some types of head and neck can­ of one such study are shown in table 7 in cer pain are well treated in this way. which approximately 50 per cent of patients A question still remains as to why various were completely relieved of pain due to can­ methods of treatment appear to help approxi­ cer and another 33 per cent had partial relief. mately two thirds of patients with cancer pain, These data must also be interpreted cautiously limited to a period of months. No biological in view of the placebo effect and the fact that explanation is yet available and studies are this method has not really stood the test of sorely needed. time. Despite reported successes, our ex­ perience at The Presbyterian Hospital with Tic Douloureux splanchnic nerve block or subarachnoid alco­ A problem presents itself in tic douloureux hol block for visceral pain, especially that due which is of great interest and illustrates one to extension from hollow organs or the pan- of the reasons why anesthesiologists must be EMANUEL M. PAPPER Anesthesiology 1082 Nov-Dec. 1967

TABLE 8. Results Obtained in Trigeminal Neuralgia discontinued, of some 20 per cent, in trigemi­ Using Carbamazepine (Tegretol) nal neuralgia (table 8). The drug is not harmless in that it produces Total 97 Patients complications referable to the blood-forming Favorable 73 (75%) elements and to the central nervous system in sustained relief about 10 per cent of patients. However, treat­ ment is so useful with this drug that it has Remission 19 (20%) (Tegretol stopped) completely changed the picture of nerve block and the need for intracranial operation at our Side effects 10 (10%) Neurological Institute. It can be seen from Amols the next chart that in the third year of the drug study there were no intracranial 5th nerve operations and very few nerve blocks alert to the development of new concepts in except in Tegretol failures compared to an av­ the control of pain. The use of nerve block erage of 28.1 intracranial operations annually for treatment of trigeminal neuralgia is time- prior to the use of this drug. honored and very impressive in most reports. In fact, it was one of the favorite diseases for Shoulder Pain which nerve block was used by Rovenstine Nerve block therapy of shoulder pain, one and his associates. As is commonly the case in of the most impressive and popular procedures all painful states, it is instructive to look at the that Rovenstine used, has receded to a posi­ natural history of the disease before we at­ tion of historical interest because of the com­ tempt to evaluate the results of treatment. bined effects of anti-inflammatory agents, the Rushton at the Mayo Clinic, as early as direct injection of such substances as cortisone 1953, analyzed the natural history of the dis­ into inflamed areas in the shoulder and the ease, and showed that in trigeminal neuralgia, greatly increased sophistication of rehabilita­ approximately 50 per cent of patients had a tion procedures for these patients. It can be spontaneous remission for six months or more.9 truly said that the nerve block treatment for Approximately 25 per cent of patients had a shoulder pain is obsolete except in rare spontaneous remission for more than one year. instances. This obviously means that one is unable to judge the efficacy of nerve block or any other The Matter of Vascular Insufficiency procedure without taking into account the Nerve block was very widely used to pro­ natural history. I would think that pain re­ duce vasodilatation. It was most commonly lief in 60 per cent of patients by nerve block performed in the approach to diseases of the might not be as impressive as it sounds, un­ extremities characterized by vasospasm. The less the relief were either permanent or were most common methods used were stellate and of the magnitude of two years or more. Obvi­ thoracic sympathetic block for the upper ex­ ously clinical judgment must temper this opin­ tremities and epidural block and lumbar sym­ ion and one should not be too harsh in making pathetic block for the lower extremities. These the judgment; but it is well to keep in mind methods, too, have seen less frequent use ex­ what the story can be with and without treat­ cept for problems in the lower extremities ment. where epidural block has retained a place of The problem is even complicated by newly usefulness. Here it provides surgical anes­ developed specific drugs for the therapy of thesia as well as vasodilatation for operations tic douloureux; one of these drugs studied by that may prove to be necessary. An important Amols at our institution is Tegretol, a drug reason for the change in approach to these dis­ which is both anticonvulsive and a psychic eases appears to be the remarkable progress of energizer. Using Tegretol, Amols attained sus­ vascular surgery in which the combination of tained relief of pain for a period of two years parenteral vasodilating agents can. be used and a remission incidence after Tegretol was with reconstruction of peripheral vessels of Volume 28 Number 6 E. A. ROVENSTINE MEMORIAL LECTURE 1083 varying size, including very small vessels. be in the position, if interested in the prob­ Even nerve injury, a previously important lems, both to take part in the total care of the cause of causalgia, is susceptible to better re­ patients and to contribute to a better under­ pair with newer techniques. standing of the problems of pain. If these An example of another type of block that essentials are achieved, then a list of useful has fallen into relative disuse is stellate gan­ procedures, as seen by this observer, can be glion block for the treatment of cerebral vas­ developed, one that he owes to this audience cular insufficiency and stroke. It is now well in view of his critical and unfavorable com­ established that the major control of the cere­ ments concerning therapeutic nerve block. bral circulation lies in the Pc02 of arterial Diagnostic Nerve Block: (1) To establish blood in the cerebral vessels and not via with certainty whether pain is organic or func­ neural vasomotor tone. Therefore nerve block tional in nature. (2) To decide whether sur­ is not rational. Although never widely ac­ gical destruction or destructive nerve block of cepted, block is not used now for the treat­ a given conducting pathway is advisable, or ment of asthma in view of the greatly in­ necessary. (3) To aid in the differential diag­ creased efficiency of drug treatment of this nosis of the source of pain, e.g., pain can re­ disease coupled with the rehabilitative ap­ verberate from one area to another subserved proaches to proper respiration, and the use of by a branch of a major nerve. It is possible to mechanical ventilators. have toothache in the lower jaw originating It appears therefore that there has been a from a lesion in the upper jaw. These can significant change in the direction of diminu­ be differentiated by appropriate diagnostic tion of the importance of diagnostic and thera­ blocks. (4) The use of nerve block procedures peutic nerve blocks as a traditional form of as a research method in unraveling the com­ therapy. This is largely the result of the plexities of pain itself. changing and increasingly successful pattern Therapeutic Nerve Block—Present Values: of therapeutics with drugs and surgical pro­ (1) Therapeutic block of a temporary nature cedures. The listener has the right to expect is valuable in the management of certain self- a more definitive answer from a speaker who limited processes which would ordinarily re­ has told you essentially that there are not quire substantial doses of narcotics, or the in­ only many problems concerning diagnostic and terference with other physiological functions. therapeutic nerve block, but that the method The use of paravertebral block for the man­ has lost usefulness. How do diagnostic and agement of patients with fractured ribs is a therapeutic block fit into therapeutics at the good example. (2) The control of postopera­ present time? tive pain is a method that is insufficiently used The answer based upon analysis falls into because of problems in the extravagant use two main categories. One obvious thought is of personnel. However, where necessary and that the regional anesthesiologist who chooses where possible, the management of postopera­ to use these methods must learn more about tive pain without narcotics and without re­ precisional anatomy, the potential, the nature strictive dressings is a most valuable aspect of of, and the development of both destructive diagnostic and therapeutic block as has been agents and temporarily active anesthetics if pointed out by Bonica and by Thorpe. It his patients are to benefit. He must also be­ should be used much more often than it has come familiar with other methods of destroy­ been in the past. (3) The epidural route is ing nerves. He must take an interest in the useful when the combined vasodilatation and precise localization of his needles. He must surgical anesthesia are necessary. (4) The take a strong interest in understanding the management of pain in labor, prior to ob­ mechanisms of pain so that he does not func­ stetrical delivery. (5) Another use of epi­ tion as a technician whose results turn out, by dural block is found in patients with periph­ and large, to be unsatisfactory and who will eral vascular disease who are to undergo de­ cease to have patients referred to him for finitive operations upon blood vessels. (6) In treatment because of his failures. He must the management of pain resulting from cancer. EMANUEL M. PAPPER Anesthesiology 1084 Nov.-Dec. 1967 the method has merit if the cancer is confined References to the distribution of a readily accessible pe­ 1. Jones, R. R.: Diagnostic and therapeutic nerve ripheral nerve or to a few peripheral nerves. blocks in the management of pain associated with incurable disease, Surg. Clin. N. Amer. (7) In the study of baffling clinical problems 45: 1023, 1965. where nerve interruption will be helpful in 2. Jewesbury, E. C. O.: Insensitivity to pain, correcting the abnormal physiology of con­ Brain 74: 336, 1951. genital urinary tract disease. (8) In the study 3. Melzack, R., and Wall, P. D.: Pain mecha­ nisms: a new theory, Science 150: 971, 1965. of pain. (9) In patients where the newer 4. Shaw, Wallace M., Hollis: Medical Approach drugs have failed to provide relief. for Paravertebral Somatic Nerve Block, JAMA 148: 742, 1952. 5. Greenblatt, G. M., and Denson, J. S.: Needle Summary nerve-stimulator-locator: nerve blocks with a new instrument for locating nerves, Anesth. An analysis from an historical, physiological, Analg. 41: 599, 1962. pharmacological and clinical point of view of 6. Ritchie, J. M., Ritchie, B., and Greengard, P.: The effect of the nerve sheath on the action those elements that are concerned with critical of local anesthetics, J. Pharmacol. Exp. Ther. assessment of the role of regional anesthesia 150: 160, 1965. in diagnostic procedures and therapeutics has 7. Perese, D. M.: How to manage pain in malig­ nant disease, J.A.M.A. 175: 75, 1961. been presented. Some of the traditional uses 8. Bonica, J. J.: Management of intractable pain of this method are outmoded and have be­ with analgesia blocks, J.A.M.A. 150: 1581, come less useful. Suggestions as to those areas 1952. 9. Rushton, J. G., and MacDonald, H. N. A.: of clinical practice where diagnostic and thera­ Trigeminal neuralgia—special considerations peutic block is useful have been made. of nonsurgical treatment, 165: 437, 1957. -2- THE PHYSICIAN AND SOCIETY by Robert D. Dripps, M.D.

The Physician and Society E. A. Rovenstine Memorial Lecture

Robert D. Dripps, M.D.

So MANY PEOPLE are writing articles or making There are reasons for this apparent provin­ speeches. From lawmakers, newspaper col­ cialism. Physicians are primarily oriented to umnists, educators, labor and business leaders disease and its cure, rather than to health the rhetoric comes in a steady stream. Certain maintenance and all that this involves. They words and concepts are presented so often further face the impossible task of trying to that one becomes numb and reacts either by keep up, even though the journals which pour turning off one's hearing almost unconsciously in on them are not always worth reading. As or by thinking that if nothing is done problems was recently said, "With a new medical article will somehow go away. Many viewpoints are being published every 26 seconds, the prob­ represented by all-or-none ideas. The author lem will never be solved by speed-reading outlines the problem and offers his one and courses. What we need are courses to teach only solution. This is highly improbable. How people to write things that are worth reading can I hope to contribute under such circum­ slowly." Be that as it may, physicians have in stances? my judgment tended to neglect the main­ My belief is that in compromise, accommo­ stream of life around them for too long. dation and negotiation rather than in polariza­ Science, and particularly technology, de­ tion may lie the way. Instead of destroying spite their enormous contributions, have not institutions so that they can be rebuilt com­ provided the answers. There is, for example, pletely as the young radical left apparently the current debate over supersonic transports. would have it, instead of confrontation, are we It is estimated that for the United States to not more likely to solve problems if men of produce and test-fly two such aircraft 1.5 bil­ good will accept the best ideas from each side lion dollars will be required. Presumably the and chart a middle course? purpose of the transport is to get from point A Let me at least offer illustrations of a few to point B faster. As Tom Wicker has asked of the questions that are being asked and in­ recently in the New York Times, "What will dicate how we as physicians might contribute we do when we get there? Will we not sit in to their resolution in the triple role of inter­ traffic jams and inhale poisonous air in cities preter, mediator and policymaker. that no longer function? Once in town won't Before this, however, should we not admit we be sequestered in lonely rooms with a tele­ that in general physicians tend to have narrow vision set that mocks us with the presumption outlooks? There is nothing quite so dull, for that we are imbeciles?" example, as a doctors' party with the prac­ Within a century we have increased travel titioners off in the corner reviewing their in­ speed a hundredfold, controllable energy re­ teresting cases. Rarely does one hear discus­ sources a thousand times, speed of computa­ sion of art, politics, literature, music or, and tion a million times, and speed of communica­ this I find distressing, rarely is there expressed tion by a factor of 10 million. Are we ready by our generation constructive concern for the for all this? I think not. problems facing man today. While the scientific method does tend to make us ask for facts, does sharpen inquiry, Received from the Department of Anesthesia, University of Pennsylvania School of Medicine, while it has provided vaccines, a long list of Philadelphia, Pennsylvania. extraordinarily useful drugs, and many impor­ Presented before The American Society of Anes­ thesiologists, New York, New York, October 19, tant devices such as the pump-oxygenator, the 1970. science of humanity has not developed apace. 163 Anesthesiology 164 ROBERT D. DRIPPS February 1971 On all sides there is evidence of dehumaniza- than the single, rigid mold seen in much of tion both in life in general and in medicine in the educational system, starting with kinder­ particular. garten and ending with graduate schools. Excessive attention is paid by physicians to Teachers are "losing" students through un­ the technologic—x-rays, laboratory data, mea­ imaginative, irrelevant and dull presentations, surements of all kinds, with too little offered and students recognize this. Most examina­ the patient and his family as frightened, per­ tions and the giving of grades chiefly instruct plexed individuals. Outside medicine the same students in how to please their professors, how thing obtains. There are great pressures to to settle for orthodox questions and answers, conform, dissent is often confused with sub­ and how to suppress their own originality. version, gadgets seem more important than The ordinary lecture encourages debilitating ideas, things more important than people. We dependence. As Weiner has pointed out, a seem to forget that every man, regardless of good lecture can provide a lucid introduction his station in life, regardless of racial origin, to some particularly difficult area so that the regardless of whether he is moral or unmoral student is spared the initial paralysis of ven­ according to current standards, is worthy of turing alone into terra incognita; it can offer respect, as befits the essential dignity of men. a fundamental reinterpretation not yet pub­ We find the individual, the family, and the lished or widely accepted; and it can show a community disturbed, resentful and uncertain. brilliant man in the process of putting ideas I shall look briefly at three major areas: gen­ together. But such moments in the lecture eral education, youth, and medicine. room are rare, so rare that they do not justify The "knowledge industry/' as it has been the maintenance of a system which far more called, spends 70 billion dollars annually. typically inculcates sloppiness, omniscience, Fifty or a hundred years ago, the concept of plagiarism, and theatricality in the lecturer free public education for all represented the and passivity, boredom, resentment, and cyni­ highest ideal of a democracy. Today, a pub­ cism in the student. Alfred North Whitehead lic school monopoly seems to have developed years ago spoke out against inert ideas, re­ and, along with other crises, we face a crisis ceived into the mind without being utilized, in confidence in schools. A new college opens tested or thrown into fresh combinations. on the average of once a week. This year This is not education as you and I wish it there are more than 62 million Americans en­ to be. gaged full-time as students, teachers, or ad­ Rather, we want a critical examination of ministrators in the nation's educational enter­ accepted truths. We must believe in crea­ prise. Can we be satisfied with this behemoth? tivity. We want reasoned argument. We Several thousand years ago Plato stated that must re-examine the public school system. We "knowledge acquired under compulsion has no must explore whether compulsory education is hold on the mind." Albert Einstein, in similar essential for all as well as whether something vein, said, "It is nothing short of a miracle called college is the only allowable way of that modern methods of instruction have not growing up. What are the citizenly reasons, entirely strangled the holy curiosity of inquiry. Paul Goodman asks, for which we compel It is a grave mistake to think that the enjoy­ everybody to be literate? Is it to keep the ment of seeing and searching can be promoted economy expanding, and the standard of living by means of coercion and a sense of duty." galloping, to understand the mass communi­ The great lack seems to be failure to encour­ cations, to choose between indistinguishable age creativity, exploration, and independence. Democrats and Republicans? Have we physicians not seen how capable It is in the schools and from the mass media we are of self-education? Most of us study that so many learn that life is inevitably rou­ and learn until we die. A student can assume tine, depersonalized, venally graded; that it is considerable responsibility for his own devel­ best to toe the mark and shut up, that there is opment. Students have initiated, developed no place for spontaneity and free spirit. This and often conducted extraordinary worthwhile Goodman calls "mis-education." courses. Multiple paths must be offered rather Mention of education brings one to a con- Volume 34 THE PHYSICIAN AND SOCIETY Number 2 165 sideration of today's youth. As one wit de­ it now knows about the field. I hear doctors scribed it, "We raised this tribe of youths, offering opinions which are not consonant with packed with vitamins, orange juice and good the evidence. We are ill-informed. This opens red meat, glowing with health, smiling with a credibility gap and makes the physician-ad­ their expensively straightened teeth, affluent visor suspect in the eyes of the young, so that beyond any dream of our own youth and so when the physician does have something con­ knowledgeable that they despise us for our structive to offer it may not be accepted. We ignorance." It isn't quite like that, but there must not only be objective, but where there is some truth in it. is inadequate knowledge, we must plan and Today's students are older, not in age but in carry out appropriate studies. Anesthesiolo­ maturity. In a recent issue of Scientific Ameri­ gists are peculiarly fit for an appraisal of cen­ can, evidence was summarized indicating that tral nervous system substances and with psy­ although students continue to enter college at chologists, sociologists and psychiatrists could the same chronological age, they are roughly form a formidable team. two years more mature—physiologically, emo­ Donald McDonald has observed, "For every tionally and intellectually. In many an in­ assertion made about American youth there stance they have passed a threshold of dignity exists, it seems, an exact denial. Youth are across which they will not and should not re­ alleged to be at once sick and sane; alienated treat. and involved; political and apolitical; arrogant They can be badly shortsighted, carried and humble; naive and sophisticated; immoral away by their own prejudices, infuriatingly and religious; obscene and pure; selfish and self-righteous. And when this is so they should generous; violent and gentle; cynical and be made to know it. Anyone who lays claim idealistic. to responsibility, whether he be young or old, "These contradictions do indeed exist in should expect to be subject to responsible criti­ each person, and various youth group do cism; and when such criticism is denied the reflect various—sometimes opposed—values, individual, he is badly served. The youth also attitudes, convictions. But the contradictions may pose demands which are unwise in prin­ also reflect different values in those judging ciple and unworkable in practice. One must youth." say "no" to these. Nor are either anarchy or What strikes one observer as "youthful arro­ aimlessness acceptable. Some students seem gance" seems to another "refreshing candor." not to have much of the tragic sense of life, of Where one critic discovers a "pathological con­ that long history of struggle and failure and dition" in young people, another rejoices in the renewal that is the story of mankind. "sanity" of youth's rejection of a "sick society." One concern that I have about young peo­ The "anarchism" that sends shivers down the ple has to do with drug abuse. The process of spines of some adults is welcomed by others as growing up has always been difficult, with the a sign of "healthy anti-authoritarianism." young person constantly having to ask, "What In this situation one cannot make even am I going to do with my life?" This is the modest assertions about youth without fear of real search for personal identity. I believe that contradiction. Nevertheless, I line up solidly alcohol and marijuana can delay one's growing on the side of the young, for they have much up. If this is true a good many young people to say to us. Martin Duberman writes of them, are in trouble. I recognize further that youth "I doubt if we have ever had a generation is a time when risks are taken, when danger is . . . that has engaged itself so earnestly on looked squarely in the face and challenged the side of principled action, that valued peo­ head-on. This too can serve the young person ple so dearly and possessions so little, that poorly if to him it means that he will try drugs cared enough about our country to jeopardize for no other reason than that they are dan­ their own careers within it, that wanted so gerous. desperately to lead open, honest lives and to It is difficult to know how to approach the have institutions and a society which would drug problem, but it does seem reasonable to make such lives possible." ask the medical profession to learn more than Arthur Mandel put it in another way, indi- ROBERT D. DRIPPS Anesthesiology 166 February 1971 eating that his (and my) generation "when Physicians should know as much as any that young was programmed for scarcity, economic the young have always asked questions, have security and self-sacrifice. As parents we have had to destroy idols. We must help parents, created the conditions for our children's de­ teachers and one another to examine issues to­ mands for a fuller, more joyful life. Our chil­ gether and to point out that easy solutions and dren are trying to practice—in love, service simple answers will not suffice. One wise and beauty—what we could only preach." counselor put it this way, "What counts in life There is going on on many a campus a dia­ costs; what costs in life counts." I believe that logue between the young and the older about the young understand this, and that we can be such items as admission of minority groups, immensely proud of the majority of today's governance, Afro-American studies, discipline, younger generation. investments in corporation doing business in May I turn now to medicine and begin with South Africa or contributing significantly to medical education. environmental pollution, ROTC, the role of As any dean can tell you, medical educa­ Trustees, and many other things. Each side tion is in a turmoil. Almost every school has is learning from the other, and through these changed its curriculum, sometimes a little, discussions the universities can strengthen their sometimes a lot. We were slow to recognize essential coherence and integrity, with the ma­ that students come to medical school with vari­ jor internal elements of students, faculty and ous backgrounds and various goals and should administration drawing together rather than no longer be forced down the single track of being driven apart. The opportunity is there two years of basic science followed by two if reason can prevail. years of clinical exposure which most of us Discussion, however, cannot go on without knew. listening. I'm not sure that either the young Certain changes have been instituted. The or the older have listened sufficiently, for there number of lectures has been reduced, as has is a difference between hearing and listening. required laboratory work in basic science To be better listeners all of us have to control courses. Grading tends to be on a pass-fail our egos. As James Nathan Miller once ob­ basis only. Students participate in curriculum served, "conversation in the United States is planning, and much more of a partnership be­ a competitive exercise in which the first per­ tween faculty and students is emerging. Large son to draw a breath is declared the listener." blocks of elective time—as much as two full We must also beware of the distortion years—are available, permitting one student to caused by emotional reactions to certain words select totally different courses from another. or ideas. Table 1 shows two lists of words, Some students graduate in three years, others, representative of two different generations. for example, those earning both M.D. and Yet as one studies the lists quietly, there is Ph.D. degrees and presumably being trained much to commend in both. for academic life, may need five to six years. As the young seek a meaning in life, let us Two questions receive considerable atten­ not be so wary of our rights and so insensitive tion. How large a class should be admitted, to the rights of others. We are being chal­ i.e., are there too few physicians in this coun­ lenged by our children. Let us listen to what try, and what kind of a curriculum should be they are saying with objectivity, understanding designed for those wishing to become primary and tolerance. Change is a way of life. With­ physicians offering comprehensive health care? out it perceptions grow imperceptible and It is difficult to know whether more doctors bodies ossify. are needed, or whether better distribution and It is alleged that there is enough metabolic greater efficiency, if these can be achieved, and mechanical energy to provide a high stan­ might solve the alleged shortage; not being dard of living for everyone in North America sure, most schools are increasing the sizes of today and for everyone in the world within 40 classes; one can only hope that the product years. Yet as the young people see it with will not be diluted and inadequate. youth's harsh clarity the gulf between the pos­ Hospital-based clinical training, the current sible and the actual is widening, not closing. vogue, tends to give students extensive prepa- Volume 34 Number 2 THE PHYSICIAN AND SOCIETY 167 ration for disease conditions they will seldom TABLE 1. encounter and a dearth of experience with some they will find widespread. There is, Honor Alienation therefore, serious exploration of a learning ex­ Discipline Involvement perience outside of a hospital, in community Courage Meaningful Thrift Identify health centers, for example. This is particu­ Religion Commitment larly important for potential primary physi­ Fitness Relevance cians, or "general practitioners," as we used to Trustworthiness Values call them. As the medical educational enter­ Hard work Confrontation Morality Activism prise moves into the community it will need Diligence Ecstasy the advice and active help of community phy­ Duty Polarize sicians. I hope that you will offer yourself freely. You can have much to offer. Recognizing that man must be the master the country is receiving for its health dollar and not the slave of technology, schools are and are unhappy with what they find. Even offering courses in political and ethical biology the research programs of the National Insti­ and the social and political implications of sci­ tutes of Health seem to a few not to have entific discoveries. New courses analyze dif­ justified their cost in terms of having failed to ferent systems of health care delivery, from provide better health for all. solo to group practice, fee-for-service to pre­ There is unequal distribution of physicians, payment, and systems under public vs. private and too many citizens receive poor medical control. The student, it is also believed, must care or no care at all. Costs and rising alarm­ learn to work appropriately with physician as­ ingly, and the old system just doesn't seem to sistants, as one way to improve the efficiency work. of the doctor. This is becoming part of his But there is one important point often over­ educational experience now. Finally, empha­ looked by critics. The demands for health ser­ sis on maintenance of health in addition to the vices can be virtually insatiable, depending on management of profound illness is being recog­ a society's level of expectations and the re­ nized as an obligation of a medical curriculum. sources it wishes to allocate to them. There If this sounds like a medical school different are a number of social domains other than from the one you know, it is. But society is medicine with recognized and major claims on asking difficult questions of the medical pro­ the nation's budget, for example, urban re­ fession, and the changes outlined represent newal, low-cost housing, public transportation, some of the responses. minimum living standard, education of the dis­ The practice of medicine is also at a cross­ advantaged, pollution, crime reduction, careers roads. Former Secretary of HEW, Robert for blacks and other minority groups. There Finch, and Dr. Roger Egeberg have written, is not enough money to go around. Someone "What is at stake is the pluralistic, indepen­ has to set priorities. dent voluntary nature of our health care sys­ We do not know what the best system of tem. We will lose it to pressures for mono­ medical care is, and perhaps there is no single lithic government-dominated medical care un­ best system, since there are strong differences less we can make that system work for everyone of opinion among honest and thoughtful indi­ in this Nation." viduals. Undoubtedly, the citizen's health To the public, medical services appear frag­ practices must be changed through educational mented, uncoordinated, costly, and too often campaigns, as must his utilization of health unavailable. Infant mortality is unacceptably services. National Health Insurance is re­ high, and the U. S. is inferior to a number of garded as a virtual certainty sometime during less affluent countries when judged by such this decade. But these are details, not com­ indices as the incidences of heart disease, hy­ plete answers. The crucial question is, will pertension, and diabetes, or the number of physicians lead in the determination of what young men rejected by the military for health is best, or will someone else make policy? reasons. Congressional leaders are asking what I entitled this presentation "The Physician Anesthesiology 168 ROBERT D. DRIPPS February 1971 and Society/' believing that doctor has some­ types of physicians. The opportunity is there thing special to offer. He knows and must for you to lead, however bold this proposition learn more about human behavior, human may seem. You are accustomed to deal with frailty, human strength. He knows how adap­ the acute, the catastrophic, the urgent. Why table man can be to a variety of challenges. not view society and its needs through this He knows that man can think, plan, and cre­ wider-angle lens? ate something new and something better. He It is reasonable for you to ask, am I equal knows all this, but he is locked into a tight, to this? Recall that we were designed for narrow professional life, and this will no longer struggle. Life was never meant to be easy. do. He must begin at once to lead in the As Phillips Brooks suggested, "Do not pray for search for solutions to the seemingly insoluble easy lives. Pray to be stronger men." problems of the day. These will not be sus­ We can take on more—much more. Man ceptible to instant resolution, but with wisdom uses only a very small fraction of his capaci­ and a sound sense of values the doctor, as al­ ties—perhaps only 5 per cent. While the exact most no other, can point the way towards a dimensions of the human potential remain un­ better life. By engaging actively in the de­ known, research at UCLA's Brain Research In­ cision-making process he will benefit others stitute points to enormous abilities latent in and will develop in himself new insights and everyone. Under emergency conditions, for broader horizons. He must share himself, not example, man is capable of prodigious feats just his material gains, with his fellow men. of physical strength. Hundreds of children be­ He must believe that he has a moral impera­ tween the ages of 4 and 6 have been taught tive dictating his actions. by Suzuki in Japan to play violin concertos. In the field of medicine he can try to find Russian scientists suggest that if we were able answers to such perplexing questions as when to force our brains to work at only half their is an individual dead or how long should one capacities, we could, without difficulty, learn prolong life in the hopeless via ventilator and 40 languages, memorize the Soviet Encyclo­ circulatory support. He must reconsider abor­ pedia from cover to cover, and complete the tion, senescence, informed consent, use of man required courses of dozens of colleges. as an experimental subject, how much of lim­ Why do we not develop our potential more? ited resources should be allotted to the pio­ Herbert Otto suggests the following reasons: neering or the unusual such as cardiac trans­ 1) Low self-assessment—men asked to list plant, and how much must be devoted to pre­ their strengths and weaknesses will usually put vention of disease and better care when any down two to three times the number of weak­ citizen is ill. nesses as strengths. From early childhood we In daily life in his own community he must have learned largely by mistakes—which are help define a-new morality, a new ethic, deter­ repeatedly pointed out. This results in "nega­ mine what is to be done about the environ­ tive conditioning." ment, the slums, how bureaucratic waste can 2) The news media emphasize violence and be reduced, how a minimum standard of liv­ consistently underplay "good news." We are ing can be provided without the shocking in­ subtly driven to believe in isolation, to let equities of welfare payment seen most recently others make the decisions, and not to become in California. The list is long, and seems over­ involved. The world is seen as a threat. whelming. 3) We trust others less because of the em­ As an anesthesiologist speaking to his peers phasis on crime, assault and violence. I urge that you raise your sights and, as the The fact remains, however, that the human saying goes, "think big/' You represent a potential is enormous. We can do more. young, vibrant specialty. Anesthesiologists are But let me make one important suggestion. deans of medical schools, presidents of state Bring into your dealings the light touch. Wit medical societies, chairmen of hospital boards. and humor seem to be vanishing from the The specialty, properly conceived, is a broad daily scene, as each one takes himself more one, crossing many departmental lines and seriously than the next. Life is grim enough. bringing its practitioners into contact with all Lighten the load whenever you can. Make life Volume 34 THE PHYSICIAN AND SOCIETY Number 2 169 a bit more of a game. Laugh at yourself and signed for struggle, and has enormous others will laugh with you. potential for growth. And so to all of you may I suggest that as 6) Join with all physicians in having a col­ physicians you owe yourself and society more lective professional concern for the pub­ than you have given. Adopt all or part of the lic's health. following: 7) Emphasize the need for wisdom to be combined with wit. Don't take yourself 1) Join with the public in an analysis of or the world too seriously, for it will im­ priorities. pair your judgment. 2) Reverse the tendency toward technology 8) Be confident, for we can destroy our­ and away from ideology. selves by cynicism and disillusion just as 3) Help shape a new morality and a new effectively as by bombs. ethic. 4) Return to public service through involve­ Remember that it was a physician, Sir Wil­ ment in community affairs. liam Osier, who said, "We are here to add 5) Recognize that change is a way of life, what we can to, not to get what we can from, that the human spirit is resilient, de­ life."

-3- A WIDE-ANGLE VIEW OF ANESTHESIOLOGY by James E. Eckenhoff, M.D. Special Article

Anesthesiology 48:272-279, 1978 A Wide-angle View of Anesthesiology:

Emory A. Rovenstine Memorial Lecture James E. Eckenhoff, M.D.*

Emory A. Rovenstine was a man I knew reasonably well. I often think the clinical application of anesthesia therefore was of him for reasons additional to the attributes and contributions listed obscure. Obviously this must have been the explana­ in your program. In the mid 1930's he accepted what must have been tion in the case of general practitioner Crawford the most formidable position extant, that of organizing a department of anesthesia in one of the largest hospitals in the world—The Bellevue Long, who didn't think enough of his first application Hospital. Few would be willing to tackle such a task today even after 40 to write or speak of it for several years. But what of the years of development. learned societies and groups of physicians around the The stories Rovy told of those days were beyond imagination, but any world that are alleged to have met periodically for of you can share in them by talking with Perry Volpitto, who was Rovy's discussion? Strange! It remained for dentists needing first instructor, and John Adriani or Stu Cullen, who were among Rovy's earliest residents. In spite of the awesome service obligations, he a painless method of extracting teeth thus to apply developed a program in the 1940's that was one of the country's patented dental appliances to make the discovery. outstanding residencies. Today, perhaps, the search by Wells and Morton I am honored to be ashed to speak in his memory. would be called project-oriented; others might more

WITH YOUR PERMISSION, I would like to inspect the cynically call it profit-oriented, since the dentist with a progress of anesthesiology from its beginnings in the painless method of extraction should attract more middle 1800's to its present position. At that point, I patients and also apply more of his own patented ap­ would like to pause and look at what is happening to pliances. Emphasis is added to such cynical analysis by medical practice and medical education. The position the early attempts to patent ether as well. Two conclu­ I have held for the past seven years has given me a sions arise from study of that period: first, communi­ particularly good vantage point from which to make cation among physicians and scientists wasn't very that inspection. Finally, I would like to look ahead good, and second, a goal-oriented approach, with and speculate as to what I see as future prob­ monetary profit expected, proved successful. lems for anesthesiology. Since I've never yet planned The remainder of the 19th century was a period of ahead or speculated about anything that resulted in relative anesthetic quiescence. Ether remained domi­ total approval, I doubt that this audience will change nant in this country. Because of the built-in safety my batting average. Nonetheless, if what is said stimu­ features of driving rather than suppressing respira­ lates thought and suggests resolutions to problems, tion and supporting the circulation rather than de­ then my purpose is fulfilled. pressing it, particular expertise in administration It has always puzzled me that the discovery of anes­ of anesthetics was not envisioned as a requirement thesia eluded a host of brilliant minds when all of the for being an anesthetist. Also, during this era, the ingredients were at hand. Physicians as well as scien­ surgical procedures being performed required little tists rubbed elbows with anesthesia but failed to recog­ more than unconsciousness and immobility. Nor was nize what was in their grasp. Even the minds of the the occasional death during anesthesia of great medical professors of the time weren't attuned to what moment, because death associated with or following was in front of them. Vandam has pointed out that operation was commonplace. Surgery, however, was acute pain was not common in those days and that making progress, particularly in control of sepsis and in technique. Nowhere are the progresses of anes­ * Professor of Anesthesia and Dean, Northwestern University thesia and surgery so vividly compared and contrasted Medical School, Chicago, Illinois 60611. as in Thomas Eakins' two powerful portraits, the Accepted for publication November 21, 1977. Presented at the Gross Clinic, painted in 1875, and the Agnew Clinic, American Society of Anesthesiologists Annual Meeting, October 17, 1977, New Orleans. commissioned in 1889. The open-drop anesthetic Address reprint requests to Dr. Eckenhoff. techniques are the same, the anesthetist in one

0003-3022/78/0400—0272 $00.85 © The American Society of Anesthesiologists, Inc.

272 Anesthesiology V 48, No 4, Apr 1978 VIEW OF ANESTHESIOLOGY 273 a urologist and in the other an intern, while technique Professor of Surgery at Northwestern University in surgery has appreciably advanced. when he wrote it, and later Chairman of Surgery. Yet Not only did the complexity of" the operation not progress in Anesthesia at Northwestern moved at a demand specialists in anesthesia, neither did the pace quite different from what one would suspect volume of surgical procedures justify specialization. from such words of support. None of the succeeding The minds of most surgeons were occupied elsewhere; chairmen until the present incumbent gave much only an isolated voice or two was heard about the need support for anesthesia; in fact, one chairman publicly for someone trained in anesthesia at the head of the degraded it as a specialty for physicians. Sixty-five table. Few, if any, thought physicians were needed, years were to pass after Murphy's statement before but only someone accustomed to giving anesthetics. anesthesia was to be recognized as an academic disci­ The nurse was asked to fill that void near the end of pline rather than a hospital service activity and be the century. One could perhaps characterize the granted departmental status at Northwestern. period as one of lack of advancement, failure of There is little question that in the early 1900's sur­ demonstration of need for specialization, and failure geons set the pace so far as the future of anesthesia of surgeons to appreciate the future of- their own in academia was concerned. In 1908, interns and specialty, thus comprehend the need for anesthesi­ junior surgeons administered anesthesia at the Uni­ ologists. versity of Pennsylvania until Senior Surgeon White The third period in our development, as I see it, went to the Mayo Clinic for an operation. He was so began in the early years of the 20th century. Ad­ impressed with the anesthesia given him by a nurse mittedly, the boundaries of my periods are fuzzy and that he returned to Philadelphia and instituted nurse the periods overlap. Surgical procedures were becom­ anesthesia. Nurses continued to provide all anesthesia ing more complicated and were invading the body •there until 1938, when a surgeon of vision, I. S. cavities with some regularity. All must not have been Ravdin, insisted on a Section of Anesthesia directed well, with the relatively inexperienced administering by an anesthesiologist. On the other hand, in 1909 at anesthetics, and presumably even the training of Temple University, Surgeon Babcock, depressed at nurse anesthetists of the period lacked structure or the death rate associated with general anesthesia given depth. In 1901, John B. Murphy, the famous Chicago by interns—one in 500 administrations, turned to surgeon, was to write: spinal anesthesia given by the surgeons, the practice to continue for the duration of Babcock's tenure. As to the future of anesthetization instead of present hap­ hazard methods of administering anesthetics, proper methods Outside of academia some physicians were recogniz­ will be taught by those competent to teach, not by any means ing the need for physician anesthetists and were the surgeon. He is not an anesthetist, but a surgeon. To effectively pleading its case. In 1905, the Long Island follow his teaching in this subject would certainly be de­ Society of Anesthetists, precursor of the American cidedly bad for the patient in many instances. More thought Society of Anesthesiologists, was formed. F. H. will be given to the selection and administration of anes­ thetics and no patient's life will be jeoparded by the use McMechan arranged publication of the American of one anesthetic when danger might be avoided by the proper Journal of Surgery Quarterly Supplement of Anesthesia & selection of another. Analgesia in 1914, and several years later, the Yearbook The hospital only can lay the foundation for the skilled of Anesthesia &f Analgesia, to be followed in 1922 by anesthetist as it does for the surgeon. The anesthetist will Current Researches in Anesthesia and Analgesia. E. I. not be considered a mere satellite of the surgeon, but recog­ McKesson, another Ohioan, devised anesthetic ap­ nized as one of a distinct class. There will be an incentive paratus, wrote extensively on the subject of anesthesia, to men to give their best energies to the perfection of anes­ and was influential in the lives of physicians who be­ thesia, the old cry for a safer anesthetic will become a thing of the past, anesthetics used will not so often be blamed for come anesthesiologists. It is interesting that the Mayo results which are really due to their abuse—then there will Clinic opted to appoint John Lundy director of anes­ be a supply of skilled anesthetists throughout this country thesia in the early 1930's when its nurse anesthesia sufficient to meet the demand. program had been so successful, but I'm told that The matter of the anesthetist's fee has always given trouble John accidentally met Will Mayo in Seattle and per­ and hindered the development of the specialty. There is but suaded Dr. Mayo to hire him. At the University of one way of deciding this part of the question and that is to Wisconsin, surgeon E. R. Schmidt happened to meet have the anesthetist's account rendered directly to the patient Ralph Waters because of Water's interest in the and not to the surgeon. pharmacologists at Madison, and was so impressed I find such a strong statement from Surgeon with him that he asked Waters to come to Wisconsin Murphy fascinating, considering the fact he was a and form a Section of Anesthesia in 1926. There is Anesthesiology 274 JAMES E. ECKENHOFF V 48, No 4, Apr 1978

little question that these two appointments accelerated gists and hospital administrators openly opposed to the growth of the specialty. Considering what was anesthesiologists, the young specialty faced an uphill happening to the expanding horizons of surgeons in battle. Nor were things peaceful in academia. Most the 1915 to 1930 period, it is surprising that the medical faculties saw little evidence that anesthesi­ growth of anesthesia was not encouraged more vigor­ ology was an independent discipline and were reluc­ ously by the surgeons, but, as Long put it in 1915, "If tant to create autonomous departments or give faculty the administration of anesthesia were not looked upon appointments of stature equal to those in surgery, as a trivial matter by the majority of surgeons and medicine or the basic sciences. Many anesthesiologists hospitals, and if the expert anesthetist were accorded didn't help the situation by their demands of estab­ the same recognition as a consultant, as were men in lishment of equality by fiat rather than by demon­ other specialties, there would be no anesthesia problem stration of equality by knowledge or practice. The for solution." non-medical faculty of universities watched these From my point of view, the fourth period in anes­ goings on with amusement; they considered medical thesia in this country began with the appointments schools to be trade schools and didn't understand of Waters and Lundy. These two men systematically what anesthesia had to offer anyway—a condition taught good anesthetic techniques, challenged the that continues to exist in too many universities today. intellects of young physicians, and trained a new breed Nonetheless, the period between 1930 and the mid- of specialists, who spread around the country to start 1960's can be characterized as one of growth, ending their own teaching programs beginning in the mid- in the unmistakable signs of maturation. By 1965 a 30's. Shortly thereafter, World War II broke out and high point had been reached in numbers of training the need for both physician and nurse anesthetists programs, and in fact these were diminishing in num­ in the services escalated appreciably. Nurse anesthe­ ber as the standards were elevated and some weak tists provided the principal anesthetic needs of the programs deleted. Recognition as a discrete specialty civilian population. As their technical skill improved was assured by the fact that nearly every hospital and with experience, many surgeons were loath to switch medical school had an autonomous department and to physicians, since some were of lesser technical anesthesiologists had appropriate faculty status. experience, nor were they pleased with the prospect of Neither powerful surgeons nor hospital administra­ another specialist in the operating room sharing re­ tors could any longer obstruct the specialty; in fact, sponsibility for patient care, so the "Captain of the in many locations they became strong supporters of Ship" controversy surfaced. The end of the War re­ anesthesia. The sphere of influence of anesthesiolo­ leased into civilian life hundreds of physicians and gists had broadened; instead of confinement to the nurses variably trained in anesthesia. The supply of technical aspects of administering anesthetics, they anesthetists in civilian hospitals increased markedly, were now active in recovery rooms, intensive care the demand for training in anesthesiology burgeoned units, pre- and postoperative care, outpatient clinics, and, as Betcher has pointed out, the number of train­ and pain clinics. Areas of special interest had ap­ ing programs quintupled in four years. Many physi­ peared, and some confined their activities to pediatric, cians exposed to anesthesia in the service for the obstetric, cardiothoracic or neurosurgical anesthesia. first time realized the opportunities, recognized the Numerous national organizations with large member­ need for basic knowledge in the field, and joined the ships gave effective forums for education, clinical academic movement. standards, publications, and voice on the medical as At this time more than a few hospital administra­ well as governmental scene. The American Board of tors looked upon nurse anesthetists as a source of in­ Anesthesiology had established itself as a leader expensive service, the income from which helped to among certifying bodies, and anesthesiologists com­ defray the expenses of other areas of hospital care monly appeared in prominent positions in the medical that did not pay. They were not enthusiastic to see and educational world. Many departments of anes­ physicians move in with higher salary demands or de­ thesiology had developed strong research units, the sire to generate income for development of new de­ output from which was accepted without question by partments. The resulting conflict had three effects. It peers. By the end of the 1960's, anesthesia was well led to a concerted move by organized anesthesia for into a period of stability and comfortable acceptance "fee for service," it caused many hospitals to resist by all. the move toward anesthesiologists, and it alienated Since becoming a medical school Dean, I've become nurse anesthetists and physician specialists. Given acutely aware of some of the trials and struggles of surgeons unconvinced of the need for anesthesiolo­ other specialties as they seek to establish or retain their VIEW OF ANESTHESIOLOGY 275 own places in the sun. I've lived through most of the attempts of government to dictate who can or cannot period of growth just described and, in fact, was inti­ go into medicine must be viewed with alarm. If suc­ mately involved with most of it. Many of us acted as if cessful in medicine, why not in every other walk of life? anesthesia alone was the discipline trying to gain Not withstanding the doubled output of physicians, recognition, so we never paused to realize what might pressure is still being applied to increase the num­ be going on in other peoples' houses. There are a bers of students and of medical schools. Proposals for lot of other specialties and subspecialties today that new schools appear from nowhere and overnight. are not stable and are just as uneasy as we used to be. Some are urged by legislators who do not understand Protection of territorial rights is the order of the day. the medical educational process and are less interested One could point to a surprisingly large list of problem in quality of physicians graduated than in quantity. areas. As examples: the attempt of oral surgery to be Other new proposed medical schools, it may surprise recognized. Try sometime to get a plastic surgeon, you to learn, are fly-by-night money-making schemes. an otolaryngologist and an oral surgeon to define their Several are enrolling students without having class­ own specialties and compared with those of the others. rooms, laboratories, hospital affiliations, or libraries, Listen to the growing pains of physical medicine; or, I might add, accreditation. One such "institution" it sounds like anesthesia 30 years ago, with difficulty wrote and asked whether its students could use our in recruitment of high-quality trainees, conflicts with library, and would we please send a complete list of other specialists, and even indulging in the mistakes all of our volumes. No one seems willing to challenge some of us made in trying to gain recognition by the impetus for more schools, more students, and fiat rather than by demonstrated ability. Remember­ more doctqrs. The losers in the end will be the public, ing the pleadings for promotion of some anesthesi­ in tax dollars, and patients, in the lower average ologists with skimpy curriculum vitaes and bibliogra­ quality of their physicians. Anesthesia must be con­ phies, I find old experiences recalled as I hear many scious of what is happening, encourage its training psychiatrists explaining why they should be promoted programs to retain high standards, and resist erosion with fragile evidence of scholarly activity. Even by external forces. among the basic sciences, there are those having dif­ During the last 15 years, anesthesia in this country ficulty gaining or retaining status as a discipline. has had an enormous influx of foreign medical gradu­ What of the period that we are now in, which I have ates; in fact, for a few years more foreign graduates characterized as one of stability and recognition? It than American graduates entered first-year graduate would be wrong to imply that in this period there have training programs in the United States. Anesthesia been no changes, or that there will not be more in the received a significant proportion of them. There is next few years. We are experiencing profound nothing strange in this; were I a foreign medical changes that can severely impact anesthesia, although graduate, immigrating here, I would be likely to have not necessarily altering either stability or recognition. opted to go into anesthesia because the opportunities In recent years societal demands and federal govern­ have been so great. But, in my estimation, many ment have forced significant changes on medicine. American anesthesia programs did not provide good A few are mentioned to make the point: The first is training for foreign doctors, often using them only as the pressure applied on medical schools to expand pair of hands to get the daily work done; in fact, some their student bodies, leading to a near-doubling of hospitals became completely dependent upon them. the output of physicians in the past decade. This has This is in the process of changing. The laws are increased the supply of American graduates going now revised, making it more difficult to immigrate, into anesthesia, and in that sense has been good for the and a limit has been placed on the proportion of specialty. However, on the opposite side of the coin foreign medical graduates that may be in training in are the constraints imposed on medical education by one institution. This will have a serious effect on government, the unreliable funding provided for pro­ some hospitals, where difficulty will be experienced grams mandated, and the surfeit of physicians being in obtaining anesthetists to get the surgical work done. graduated, all causes for alarm. Many of us do not The result will be, in some situations, to sharply up­ believe that a shortage of physicians ever existed, but grade programs to attract American graduates; in readily agree that there is maldistribution and that others, nurse anesthetists will be substituted for resi­ physician services are often inefficiently used. A sur­ dent physicians, and in still others, the case load will plus of physicians is not going to diminish the cost be redistributed to improve efficiency of utilization of health care; it will increase it, just as too many anes­ of anesthesiologists' time. thesiologists will raise the cost of anesthesia. The The final outcome is difficult to visualize for two Anesthesiology 276 JAMES E. ECKENHOFF V 48, No 4, Apr 1978 other reasons. While the number of foreign medical 1979, 50 per cent of the graduating physicians graduates may diminish, the number of American must enter family practice, general internal medicine, graduates will increase over the next few years, the ex­ or general pediatrics. It also significantly diminishes act increase dependent upon governmental pres­ the movement of graduate physicians out of those sures. It is doubtful that the increase in American disciplines for the three years beginning July 1978. medical graduates will match the decrease in foreign This is a nationwide quota and is likely to remain one, medical graduates. The second reason is the move­ although if not reached in July 1979, the quota will ment by governmental agencies to control hospitals then revert to each medical school to meet. All of us and health care activities, including building new hos­ interested in anesthesiology have wondered how pitals, number of beds, location of tertiary-care surgi­ much this Act would affect the recruitment of physi­ cal services, renovation of old facilities, and purchase cians into the specialty. My appraisal is that it will of expensive equipment. Some small hospitals may be have only a transient effect, if that, for reasons to forced to close, finding it fiscally unfeasible to con­ follow. tinue operation. There are likely to be many urban First, I don't believe the law will remain in effect for hospitals that will have to reduce the numbers of their more than a few years. Many universities are refusing beds, and institutions involved in tertiary-care surgi­ to comply with the Act because it grants the secretary cal procedures failing to meet minimal annual limits of HEW the right to determine who will be admitted will be forced to cease these activities. In general, to medical schools and takes that right away from federal regulations will require centralization of many medical faculties. Unless all or nearly all universities medical care programs. Let me give some examples comply with the Act, I don't think that it is workable. that will clarify what has been said. The National The government could, I suppose, direct that all must Guidelines for Health Planning released within the comply under penalty of losing total federal support, last three weeks by the Department of Health, Edu­ not just capitation grants, but that seems unlikely. cation and Welfare state, among other things: A second reason is that the Act is more likely to There must be fewer than four short-term hospital affect specialties other than anesthesiology, to wit the beds per 1,000 population; surgical specialties. If there are fewer surgeons in the There should be at least 2,000 deliveries annually future, there should be less demand for anesthe­ in any hospital in an area with 100,000 or more popu­ siologists-. lation; A third reason is a personal prediction. I don't A pediatric facility of 80 or more beds must main­ believe that more than 50 per cent of young physicians tain an average occupancy of at least 80 per cent; graduating today will be content to remain in family A neonatal intensive care unit must have at least or general practice for the remainder of their 20 beds; lives. Medical knowledge is too extensive, and I cannot At least 200 procedures must be .done annually in imagine 50 per cent of physicians being satisfied with any institution doing open-heart operations, and no knowing less and less about more and more. I suspect new open-heart unit may be opened unless every other many will ultimately seek additional training in order such unit in the service area is doing at least 350 pro­ to confine their practices to an area of medicine cedures annually. where they believe they can be adequately prepared The guidelines go on and on, but I think that you and up-to-date. Many are likely to select anes­ can see what is meant. These regulations will have thesiology. The basis for my suspicion is not germane appreciable impact upon the daily activities of many to this presentation. anesthesiologists, may force some to relocate and So much for the present and the immediate future. others to change what they have been doing for years. While enormous problems face medicine, I don't see At this juncture it is hard to predict the effect on these as immediate threats to anesthesiology, or as in­ numbers of anesthesiologists that may be involved. Do terfering with its growth as a medical discipline. In not take refuge in the thought that it won't happen; the background, however, loom questions that are it has already happened! Ask any hospital director worrisome, that require careful thought and delibera­ who wants to build, renovate, or order a new expensive tion, the solutions to which may well dictate the piece of radiologic equipment. stature of anesthesiology as we move into the last Finally, in regard to the period we are currently in, decade of the century. I will pose seven questions, what of the federal regulations mandating the areas of not in order of importance, because at this moment practice that medical graduates must go into? The I have no idea of what the order should be, but current Health Manpower Act requires that by July they are all of paramount importance to us. Anesthesiology V 48, No 4, Apr 1978 VIEW OF ANESTHESIOLOGY 277

1. The education of anesthesiologists: This seems a that require more thought than the specialty as a whole logical place to start with the questions. The Anes­ has given. First is our attempt locally and nationally thesiology Residency Review Committee and the to provide qualified witnesses to courts. In too many American Board of Anesthesiology have done a litigations "expert" witnesses have been physicians creditable job of improving the standards of training who administered anesthesia only as an intern or who in the specialty, perhaps better than have most have practiced anesthesia the same way for 20 years, specialties. Long before outside pressures, the number never attending a meeting or reading a journal. of training programs was decreased by deletion of The second is the willingness of some among us to those with unacceptable standards. But are we doing become an expert witness for either side just for the enough? Are we carefully looking inside the individual pecuniary gain. Anesthesia must determine and programs? Residency review committees and specialty record who will speak for it in the courts. It must boards can do just so much from the outside. Are be prepared vigorously to defend anesthesiologists the universities or corporate boards under whose where appropriate, or appear for plaintiffs with jurisdiction residency programs are conducted look­ equal force when indicated. ing equally carefully? Are we sure that the products 4. Anesthesiologists and nurse anesthetists: The di­ of the programs are adequately prepared for as­ vergent histories of nurses and physicians in this suming their role in patient care, integrated fully field have already been mentioned. The divergence with other medical and health care services to the is regrettable but understandable. Nonetheless, a ultimate best advantage of the patient? Are the separation of these two groups is unthinkable, and educational programs truly integrated with other any attempt to equate a nurse anesthetist with an specialty training programs and not fiefdoms serving anesthesiologist is absurd. The expansion of knowl­ their own purpose? A very broad question, and edge and technique in anesthesia once the physicians deliberately left so. really got into the field should be apparent to any Monitoring the professional activities of anesthesiologists: discerning person. However, it is easy to understand Who continues to monitor an anesthesiologist and his/ how a competent nurse through years of diligent her competence once training has been completed? practice and study can be equated with a physician Who really monitors any physician once practicing? who permits him/herself to fall into a technician One of the complaints registered against physicians role, failing to participate in extra-operating-room is the lack of internal monitoring of competence. activities and not keeping up with recent advances. But then, where is the evidence that the legal It was a pleasure to me when some years ago the profession monitors its membership? The standards American Society of Anesthesiologists began over­ by which the press controls its releases often leaves tures to the nurse anesthetists for a corroborative one aghast. Nonetheless, the fact remains; because venture. It is unfortunate that a common under­ others haven't done it doesn't mean we shouldn't standing hasn't been reached. I must congratulate tackle the problem. There are in excess of 6,000 Dr. Ament for his recent forthright statement to the physicians actively practicing today, classifying them­ nurses, and I hope a change in the attitude of their selves as anesthesiologists, who have not passed a leaders results. Nurse and physician anesthetists must certifying examination. While this is only about 5 per work together—if they don't, the field of anesthesia cent of all uncertified physicians, shouldn't it be ex­ will be a public laughingstock. I do not believe amined? If physicians don't become involved with this that every anesthetic will ever be given by anesthe­ activity, then others will. I am a member of four siologists, so let's not wait for the problem to go away. hospital boards of trustees, and all are discussing this Nurse anesthetists are needed and are here to stay. point. One has already appointed a board professional We must work in symbiosis. Above all, anesthe­ standards committee, and another has appointed siologists should not allow themselves to get "painted three board members to sit with and observe the into a corner," thus being forced to divorce a rela­ staff executive committee meetings. tionship. 3. Anesthesiologists and malpractice: The need for a 5. Distribution of anesthesiologists: As stated earlier, the resolution of this problem is obvious. I'm not sure that paramount problem of the supposed physician some of the malpractice actions haven't been ap­ shortage is really maldistribution. The government's propriate, because many litigations I'm familiar with approach to this problem is to saturate the market have exposed gross negligence and incompetence— with primary care physicians, hoping that they will go for the most part by uncertified physicians practicing to small communities, rural and underserved areas. I anesthesiology. There are two points in this matter doubt this approach will work, and am sure it will JAMES E. ECKENHOFF Anesthesiology 278 V48, No 4, Apr 1978 not help regional shortages in anesthesia. What plans medicine was looking to anesthesia's future, and ap­ are being laid by the specialty to cope with mal­ parently not even the surgeons were projecting their distribution? Do some of our large urban institutions own future, because if they had, the need for develop­ need all of the physicians they have? If we don't come ment of anesthesia would have been realized. With up with a solution, don't be surprised if the govern­ the next period, characterized by the first stirrings ment develops a formula for assignment. of physician interest in anesthesia, some thought of 6. The economics of anesthesia practice: From a position the future was applied by a few surgeons, but of being "poor cousins," anesthesia has moved into the principally by physicians outside surgery. Academia ranks of the better-paid specialties. In some instances, played no appreciable part in either period, but it would appear that incomes are becoming excessive things changed beginning with the appointments of considering relative work loads, hours worked, risks Waters and Lundy, culminating with the seeding of involved, and stresses and strains on the psyche. training programs all over the country and an out­ Rather than what is the service really worth, the pouring of well-trained anesthesiologists and comple­ attitude too often is, what will the market bear. tion of important research. Maturity has arrived, Further, one senses an indifference to the costs of and it would appear that able leadership from both equipment, agents and supplies used in our daily the academic faculties and the private sector is practice. In most practices, these costs are charged guiding the specialty well. The problems are now, by the institution, not the anesthesiologist. It is however, becoming more complex, more difficult of interesting to watch a private practitioner of anes­ solution, more global in character, and perhaps more thesia who purchases his/her own equipment and sup­ consuming in time, energy and thought. plies. The manner of practice is very different. Medicine is castigated for failing to provide Anesthesiology, as well as all other specialties, must adequate health care for the nation, yet at the same become more cost-conscious and develop a realistic time most accept that the caliber of the care approach to income guidelines. More time should available is excellent. As our ex-Secretary of Health, be spent teaching the economics of practice in Ted Cooper has said, "How can anything that is so residency training programs. good, be considered to be so bad." Should the blame 7. Research in anesthesiology: For nearly 20 years the be placed on physicians or on medical education? government pumped money into research and into What is government's responsibility in this alleged training programs. Training grants have disappeared, failure? Wasn't the ball dropped decades ago when and are unlikely to reappear. Research dollars, on the Washington failed to project the future of health care other hand, are not likely to disappear, but they needs and properly plan for long range health care? are also not likely to increase. This stable state means It is interesting to speculate where we might be today competition for research dollars will increase; un­ if a president of the United States at the turn of the imaginative, unrealistic and poorly or inefficiently century had appointed a blue-ribbon task force to done research will fall by the wayside. When adequate study health care needs for the country and propose funds were available, some research done by anes­ a plan for meeting those needs. The maldistribution thesiologists was excellent and knowledge in the and inefficient use of physicians and of health care specialty was vastly improved. We must find ways to facilities would probably be different today. We can­ continue to support research in departments of not repeat the failures of the past periods in anes­ demonstrated excellence. My personal bias is that a thesia, nor those of the country in health care. We closer union between basic science and clinical dis­ must plan for our future. ciplines in universities provides the most likely route With a faculty of 1,500, I've come to know that for success in this area. I perceive the days of the most successful way to deal with complex problems the autonomous self-supporting research unit in clini­ is to appoint a group of thoughtful faculty cal departments to be disappearing. members, administrators and students representing This concludes my list of concerns. The list is all aspects of the problem to be solved, and charge formidable and the answers are not readily available. them to recommend solutions. Perhaps a president of But the problems must be kept in plain sight, on the the American Society of Anesthesiologists might find it table in front of us, for open discussion. profitable to appoint one or more advisory groups In my development of the history of anesthesia in with appropriate representation from within and this country, it was pointed out that during the without the specialty to make recommendations to its period ending in approximately 1905, no one in Board of Directors. Such groups could consist of Anesthesiology V 48, No 4, Apr 1978 VIEW OF ANESTHESIOLOGY 279

anesthesiologists from both the private and academic prestigious individuals from all walks of life to ad­ sectors, hospital administrators, surgeons and other vise solutions to problems and project for the future. physicians, nurse anesthetists, attorneys, businessmen, We should be able to do this, too. and perhaps government or consumer representatives By careful selection of advisory committees, ap­ where appropriate. Care must be exercised to select propriate charge by the president or board of direc­ unbiased people, avoiding those who want to protect tors, and thoughtful discussion over a realistic time their territorial rights. Few outside of medicine think frame, it should be possible for the Society to deal that physicians alone can deal adequately with health satisfactorily with these seemingly insoluble problems. care problems, because physicians have too many We should be able to avoid the crisis management that vested interests. Therefore, you must consider only has become so characteristic of medicine today. those who can deal with the facts and recommend Remember: physicians want someone who will level what is best for all. with them, whether it be about TV sets, automobiles, I know the Society is dealing with several of stock investments, or housing. The lay public wants these problems, but doubt that all are under the the same sort of information about physicians and active and broad consideration that seems to me to be hospitals. necessary. As a member of the executive committee Thank you for the privilege of delivering these of the National Board of Medical Examiners, I am observations on behalf of the memory of Emory A. impressed how readily that Board can call on Rovenstine.

ANESTHESIOLOGISTS AS CLINICIANS by Leroy D. Vandam, M.D. Special Article

Anesthesiology 53:40-48, 1980 American Society of Anesthesiologists Rovenstine Lecture—1979:

Anesthesiologists as Clinicians

Leroy D. Vandam, M.D.*

IN READING the journals these days, one can hardly anesthesiology, for this kind of medical activity has fail to sense an uneasiness that pervades the medical never been among our strong points. Thus, my caption world. What can be the reason for this malaise? Per­ for a Rovenstine Memorial Lecture—"Anesthe­ haps this is not a new phenomenon, but a mere glance siologists as Clinicians." at some of the articles provides the clue; some written E. A. Rovenstine (figs. 1 and 2), at whose lectern by practicing physicians, others by educators or re­ I have sat, along with a host of others, during his searchers—still more by the professional writer and renowned courses on nerve blocking procedures in critic or an occasional articulate patient. Just to cite a the therapy of pain, was truly a clinician who cared few: George Engel, respected psychiatrist and inter­ for patients in a total manner, considering all of the nist of Rochester, New York, ponders on "The Care of ramifications, because that is what the treatment of the Patient: Art or Science"1; June Goodfield, scientist pain is all about. Some call this holistic medicine, not to at the Rockefeller University, gives us her views on make a pun, but according to the philosophical tenet "Humanity in Science"2; Ronald Carson of Florida that the determining factors in nature are wholes, queries, "What Are Physicians For?"3; John Burnum not their constituent parts. For your edification, I of Alabama writes about "The Malaise in Internal would further define the meaning of the designa­ Medicine"4; meanwhile, Michael Radetsky, a physician tion—clinician. Derived from the Greek, meaning from San Francisco, would "Recapture the Spirit in bed, the adjective applies to the sickbed, and over the Medicine"5; and William Regelson of Virginia be­ last century or so, to hospitalized patients. John moans "The Weakening of the Oslerian Tradition."6 Lister of London,9 correspondent to the New England Aiming at some of the causes of the affliction, Lewis Journal of Medicine, notes that it is therefore correct Thomas, admirable prose writer, suggests how we to speak of such things as clinical tuition, clinical might "Fix the Pre-Medical Curriculum,"7 and one research and clinical problems in reference to patients, Anthony Moore from down under sounds off on particularly when they are confined to bed. But, as "Medical Humanities—A New Medical Adventure."8 you know, language undergoes a subtle perversion These references constitute just a small sampling of with the passage of time in that "some have come to the articles I have culled over the last few years in associate the word 'clinical' with the cold, detached anticipation of the possibility that one day, in the and functional surroundings of the laboratory. Ac­ twilight of an academic career, I might be asked my cordingly, new bathrooms or well-equipped kitchens views on the standing of anesthesiology in the medical are considered desirable when depicted as having a hierarchy and where we might expect to be when the clinical atmosphere." So is this form of address pennant race is over. You should have surmised by perverted when a nondiscerning surgeon believes his now that the laments implied in title form embrace consulting anesthesiologist to be a slick clinician because a common theme—a witnessing of a change in our the trachea was intubated in a trice, cerebrospinal relations with patients and a plea for the return of fluid recovered upon first pass of the lumbar puncture humanistic medicine. This being so, and somewhat needle or a central venous, jugular or pulmonary- caught up in the hysteria, I have been worrying about artery catheter inserted in a twinkling with no im­ mediate catastrophe. Though manual dexterity is the * Professor of Anaesthesia, Harvard Medical School; Anesthesi­ least that one might expect of a surgeon or anes­ ologist, Peter Bent Brigham Hospital, Boston, Massachusetts 02115. thesiologist, that definitely is not the quality of a Accepted for publication January 18, 1980. Presented at the clinician. Dickinson Richards, Nobel Laureate, once annual meeting of the American Society of Anesthesiologists, San Francisco, October 22, 1979. remarked that a stethoscope cannot function without a Address reprint requests to Dr. Vandam. man at each end—the same is true of a scalpel,

0003-3022/80/0700/0040 $00.95 © The American Society of Anesthesiologists, Inc. 40 LKCTURK 41 ophthalmoscope or throat stick. Physicians can learn medicine only from patients. Would you accept this as an introduction to this colloquy? A clinician is a doctor of patients and their illnesses, someone who derives satisfaction and moral uplift in understanding them; and because of the perceptive, gentle care bestowed, engenders the same feelings in those treated. I am quite aware that this is a sentimental, even an Utopian concept in the current arena of patient activism, governmental prying and the spectre of lawyers hovering in the wings. These constituencies, too, lament the disappearance of their conceptual image of the physician, and frustrated, they focus on, among other matters, the rising costs of medical care. That medicine should be besieged by criticism, even ridicule, is an age-old phenomenon. From the

FIG. 2. Rovenstine at the height of his career in anesthesiology. The portrait reveals the intelligence, inquisitiveness and sense of humanity that typified his career as a leader in anesthesiology.

time that physicians, particularly surgeons, emerged from the crowd of healers with a clear image of their reputed special qualifications in caring for the sick, they became the targets of satire. Witness these mordant caricatures from the British and French schools (figs. 3-6) — trenchant, transparencies of the superficiality of those posing as healers to the sick. The playwright was equally good in sensing the foibles of the profession. For example, Moliere, who analyzed life and clothed his analyses in theatrical form, considered all healers to be quacks. Thus, he T had great sport in the one-act comedy "The Flying Doctor," where Sganarelle, a valet, posing as a doctor in the usual stereotyped intrigue, says, "I bet I can confuse matters as well as all the doctors in this town put together, or kill patients as easily. You know the old saying, 'after you're dead the Doctor comes,' when FIG. 1. E. A. Rovenstine as leacher, coach, and athletic director I lake a hand there'll be a new saying, 'After the Doctor at La Forte High School in Indiana. The photograph and tribute to comes, you're dead'.""1 him highlight just a lew of the qualities that later led to his eminence in medicine and the specialty of anesthesia. Perhaps George Bernard Shaw put it all together in 42 LEROY D. VANDAM

thesia have made operations much less serious than \B£L FMVRE they really are. When doctors write or speak to patients about operations, they imply, and often say so in so many words, that chloroform has made surgery pain­ less. The patient does not feel the knife and the operation, therefore, is enormously facilitated for the surgeon: but the patient pays for the anesthesia with hours of wretched sickness; and when that is over, there is the pain of the wound made by the surgeon, which has to heal like any other wound." Almost simultaneously, in the first decade of this century, Frederic Hewitt, Dean of British anaesthe­ tists, was writing the preface to the third edition of his textbook, Anaesthetics and Their Administration. "Curiously enough," he says, "there are still thousands of educated men and women who look upon the process of anaesthetization as practiced by the now large body of special anaesthetists as corresponding in importance to poulticing, bandaging or some other purely me­ chanical procedure—and who have little or no idea that the success of even the simplest surgical opera­ tion may be dependent to a large extent upon the FIG. 3. A French satire which speaks for itself as the anaesthetist." A familiar plaint! physician examines a probable dowager. I like to fancy that the anesthesiologist's problems his essays on "The Doctors' Dilemma,"11 containing in being a clinician began when anesthetist and surgeon headings such as these: "Credulity and Chloroform," got together for the first time. According to N. P. Rice, "The Social Solution of the Medical Problem," "Doubt­ in Trials of a Public Benefactor, the official biography,12 ful Character Borne by the Medical Profession," W. T. G. Morton, in anticipation of the operation, is "The Craze of Operations," and "The Society of Self believed to have had misgivings. The first unfavorable Respect in Surgeons." Here is one of his statements fact being that Morton knew that the effects of ether that applies equally well to anesthesia. "Patients are upon various persons were wholly different—excite­ encouraged to imagine that modern surgery and anes­ ment—or death in the debilitated. He muses, "If this

FIG. 4. From (he English school in the tradition of Rowlandson, Hogarth, flat.: "The palieni turned doctor, or the physician forced to lake his own stuff." experiment should result adversely, should I not be charged with its fatal issue?" "A second unfavorable fact in the case was his entire ignorance as to what his patient might be: whether some hardened toper, saturated with strong drink upon whom his prepara­ tion might produce no more effect than his ordinary daily "nipper" or some delicate, timid female who would tremble and be overcome at the very thought of being experimented upon." One can sense that Morton was a clinician at heart in his understanding of people, as evidenced by a now prototype preanesthetic inter­ view (fig. 7). Upon entering the amphitheatre, W. T. G. stopped at the bedside of the patient. Taking the man by his hand, he spoke a few encouraging words to him, assuring him that he would probably relieve, if he did not entirely prevent, pain during the opera­ tion, and pointing to Mr. Frost, told him that there was a man who had taken it and could testify to its success. "Are you afraid?" he asked. "No," replied the man, "I feel confident and will do precisely as you tell me." In four or five minutes he lay as quietly and

Fie. 6. Another thrust by Daumier. "A lucky find." "By Jove, I'm delighted! You have yellow fever ... it will be the first time I've been lucky enough to treat this disease!"

soundly asleep as any child in that curious state which is, "Twixt gloom and gleam. With Death and Life at Each Lxtreme." One hundred years later, anesthesiologists were still ruminating over their precarious relations with patients. As an itinerant guest speaker in the forties, I can recall attending many a local society meeting and listening to endless debate over the need to im­ prove the image of the profession. Often the sug­ gestion was put forth that a public relations expert be hired for the purpose. But, happily, the clinician in the audience would exclaim that the only remedy was for every anesthesiologist to visit his patients personally, before and after operation. As there were millions of anesthetics given annually, what better means was there for the aggrandizement of anesthesia? At the time, more than a few individuals editorialized in the same vein. For example, in 1950, W. T. Salter, a pharmacologist of Yale, wrote about "The Leaven FIG. 5. Lithograph by Honore Daumier. "Le debut." The Be­ of the Profession."13 "At this juncture, however, those ginners—Berirand: "Oh no, (he patient is weak, she wouldn't survive: the operation is impractical." Robert Macaire: "Impractical!!! who have the future of anesthesiology close at heart Nothing is impractical for a beginner. Listen, we have no name yet will realize that no professional specialty can maintain among the profession. If we fail, we don't lose anything. If, itself on the basis of service alone. It is true for anes­ by chance, we succeed — well, we'll be launched, our reputation will thesiology, as for any other profession, that service be made." Both: "Let's go ahead then." 44 LEROY D. VANDAM

Fie. 7. Hinckley's Ether Day painting. Gilbert Ab­ bott, patient, is the lotus in center. William Thomas Greene Morton, anesthe­ tize!", stands 10 the patient's right.

must be leavened with progressive thought." Here they were professionals, consultants to other doctors he was making a plea for "a sprinkling of investigators caring for the operative patient—whereby by virtue to guide and lead it on its path forward." I believe of special training, skill and experience they were that we have more than answered his exhortations in free to make crucial decisions in their functions as that regard, but Salter made some other generaliza­ anesthesiologists. Perhaps many of us in anesthesia tions that are basic to my concept of the clinician. "It have now arrived, for I can assure you that once a must be appreciated that the future representatives of patient or a surgeon has encountered one of our breed, anesthesiology, as in all professions, should be hand- there can be no question in his mind regarding the picked for general background and cerebration. kind of medical treatment received, or the unlikelihood This is particularly true of anesthesiology where of its duplication by anyone else. But I do know that there is a danger of overemphasizing technics and a large corpus of the old variety still survives. Later in gadgets." his essay, Lortie began to have a glimmer of the Dominant issues always seem to come to a head at qualities inherent in those who had "arrived"—those the same time after years of submergence. In that who stood in a different relationship to many per­ same year, Dan Lortie delivered before the Inter­ sons, who saw their patients before and after opera­ national Anesthesia Research Society a paper, "The tion and were known to them — free to initiate the Sociologist Looks at the Profession of Anesthesiology."14 type of anesthesia indicated and able to beat new His conclusions were based on interviews with many paths in anesthesia practice. "They may be called anesthesiologists working in various places, under in consultation on problems that in other hospitals various conditions, on his observations in hospitals would be considered far removed from the jurisdic­ and operating rooms, attendance at medical gather­ tion of an anesthesiologist." ings, and perusal of the relevant literature. Once Some of you in this hall will recall that in 1962, ten again he found an ambiguity of the anesthesiologist's years after Salter and Lortie made their pronounce­ status, resulting from the fact that there was no clear- ments, the House of Delegates of the American Society cut definition of the job in regard to anesthesia. In of Anesthesiologists sanctioned a study of the status of many places in America, the work was defined as anesthesiology in the areas of practice, research and "nurses' work." Patients, hospital personnel, and teaching. A preliminary report of the findings, in 1964, physicians expected the function to be executed by a once again reflected upon the credibility of the anes­ nurse—a low-status and subordinate one. However, thesiologist as a clinician.15 Medical students inter­ Lortie also observed that not all anesthesiologists viewed, those whom we would recruit early in their shared a similar state, because many had "arrived" — careers, revealed that central to their thinking was Anesthesiology ROVENSTINE LECTURE V53, No 1, Jul 1980 45

the image of medicine as a ministering way of life— he avers, "the British are given a freer rein to practice the satisfaction of helping patients and the status of the overall care of the patient. For instance, in private professional position. But, they felt that neither of work, I do all of the medical care of the patients I these compensations was obvious in anesthesiology. have, and my surgeon trusts me to do this. In America, The same dilemmas were unearthed among the interns it seems to me that a specialist is called in right from polled, and a general dissatisfaction with anesthesia the start. In the National Health Service here, the residency training surfaced. In the universities, the scene is more like your overall picture because the professors seemed to believe that if practitioners were system has killed off the "special relationship" that much more interested in patient welfare and less used to exist between surgeon and anaesthetist and concerned about easy hours and high income, a better still does in private work. But here's the catch—it example would be set and recruiting would be easier. all depends upon the people." Conversely, non-university program directors ap­ Last, another graduate of the British system, inter­ peared to believe that the professors failed to recruit nationally peripatetic in his practice, believes that my because of inadequate teaching activities and that query is very controversial and very relevant to present- anesthesia was on the whole poorly practiced in uni­ day practice. In general, he echoes the opinions of versity hospitals. Obviously, there was considerable the others; but insofar as postoperative care is con­ ignorance of each other's activities in both camps. cerned, he has found his cohorts sadly lacking in this Ironically, we may have silenced a useful dialog by a respect. "This indeed," he adds, "may be more of a gradual phasing out of the non-university training reflection of a true clinician from a medical and per­ programs. sonal standpoint than any other aspect of the anesthetic Because I wondered whether this all might merely care of patients." be an American affliction, I wrote to several able A worthy description of the anaesthetist, no matter anaesthetists in Canada and abroad, to inquire whether the land, may be found in D. D. C. Howat's recent their countrymen had a better opportunity to play the Frederic Hewitt Memorial Lecture, in which he dis­ role I had in mind. I respect their anonymity, but you coursed on the subject, "Anaesthesia as a Career."16 may be able to identify at least one or two of them As a result of a questionnaire more comprehensive by reason of their beliefs. A correspondent from Wales than mine, Howat was able to paint this picture. "I is apparently a learned fellow, as he readily quoted am convinced that the anaesthetist must be as good at Shaw from memory as one who defined the pro­ his craft as the surgeon is at his. Whatever other fession as being a conspiracy against the laity. So the interests the anaesthetist may have, whether it be Welshman answered, "Having been to Sweden, intensive care, the treatment of chronic pain, or Australia, and America, my general impression of the respiratory pathophysiology, his foundation must always overall care from a personal and medical standpoint be the administration of anaesthesia. As for the type of is that it is strongest where the individual contact person who chooses anaesthesia for a career, I am not between the doctor and the patient is closest, and that sure that I can be so precise about the prototype usually means private practice no matter the country. as I am about the surgeon. I suspect our surgical col­ Obviously, this is best upon a scientific background." leagues might be more articulate. There is undoubtedly My Canadian acquaintance asserted that there is no an element of satisfaction in the fact that for a time the pat answer to the general question, "I know many patient's life is in one's hands. It would be dishonest first class clinicians amongst the anaesthetists in not to recognize it; but the sense of responsibility Britain, Canada, and the United States; and, at the which goes with this knowledge of power is, to say the same time, I am aware that in all three countries we least, sobering." After relating the pleasures of applying have technicians and scientists who look after their physiologic and pharmacologic principles and the patients badly. Much has to do with the details and satisfaction taken in one's technical ability, particularly orientation of training. In America, the definition of in a difficult case, Howat arrives at the essence of a the anesthetist as a clinical pharmacologist seems to clinician. "An important reason for being an anaesthetist be the most popular. The inclusion in our training is that we feel we can actually get to know our patients, programs of a compulsory year of training in internal as well as do something to cure and relieve suffering, medicine has undoubtedly influenced the attitude of instead of merely making surgery possible, laudable our trainees toward their patients." though that is." Now back to Harley Street in London, where my Thus, we are drawn again and again as the moth is informant finds it difficult to discern whether the to the flame, to the central theme—our relations with British anaesthetist is a better clinician than the Ameri­ patients. I have not intended to harangue you, for if can. "However, due to the differences in the system," the system has not worked out as well as we would LEROY D. VANDAM Anesthesiology 46 V53, No 1, Jul 1980 have hoped for, I as a representative of the teaching Poem class am as much to blame as anybody, working within "Don't leave me." As if to say: a unique and seemingly circumscribed medical specialty. "Hold me while I'm asleep. Apparently, we must rely largely upon the pre- and Watch they don't cut too deep. post anesthetic visits for our major thrust as clinicians. Watch them." "THEM" — the mutilators, the deaths in childhood dreams. I will proceed now to some of the highlights of these functions, according to my own personal prejudices. "I'll stay with you." The logistics of the preanesthetic visit are not easy to You—the memory of your voice, your love of living that stood solid, someplace, cope with. Those in the subspecialties may have the behind the fear which made you hold my hand. better opportunity. A cardiovascular anesthesiologist should be able to see his patients over many days The beating of your blood drums in my ears, my hand pumps in your breath. ahead of time, and so goes it with his obstetric counter­ My brain serves both our bodies. part in the prenatal clinic. Also, the unselfish surgeon Mine sooner has the knowledge of your doom. realizes that as a result of early consultation, the very My fingers, knowing, hold your lungs expanded ill patient will benefit psychologically and physiologically and then let go: a sigh of mourning. in discerning that an expert and compassionate I have to let you wake so you can make your death your own. physician-anesthetist will see him safely through the operation. Nevertheless, you are aware that, for the Obviously, the right kind of visit will take time and host of anesthesiologists, the preanesthetic visit is the stage thereby set will be affected by a number of enabled only at inconvenient times, often because of subtle influences. What goes through a patient's mind late admission to the hospital of the patient or pre­ when the interviewer appears at the door in a rumpled occupation with a prolonged operating schedule. Just operating suit, perhaps still wearing shoecovers—hard as frequently, the anesthesiologist has long since gone to distinguish from the aide who had just swept the home, but it would still be possible for him to return floor. Dressed as a consulting physician, pick the right for this essential engagement. As a rule, especially time, please be seated, not on the bed—none of this when the schedule for the next day is long and com­ standing in the doorway. Then an encounter ensues plex—a shifting scene of encounter, with additions wherein each participant assesses the other. After and cancellations—or when the anesthetic is to be introductions, a good conversational opener is to talk given by a nurse or a resident who has the day off, first about other matters, often directed by the reading one or two anesthesiologists perform all the pre­ material the patient has taken along to while away anesthetic interviews. The result is always a per­ the hospital hours. This is when the anesthesiologist functory encounter, merely going through the litany of substance and background scores his first points. of JCAH requirements, with an eye toward medico­ No need to list the routine questions here, but a legal consequences, and filling out a form that another physical examination and the establishment of your anesthesiologist will review shortly before induction of own surgical diagnosis tend to convince the patient anesthesia. Thereupon, others may substitute during that you are thoroughly informed of his problems. the course of the anesthesia; some going out for a But do not let on that your diagnosis does not agree refresher, another for a lunch break, and still others with the surgeon's, by innuendo or otherwise. The as the day shift changes. No matter the circumstance, real exchange, however, and a fascinating one, is the this strange and dangerous sequence of events need psychological assessment, trite as that may sound. not occur. How insignificant must anesthesia seem to Look to yourself when annoyed by the patient's queries, the surgeon and other operating room personnel if it his apparent obstinacy or seeming ignorance. Let us matters little who gives the anesthetic, which is often not be rattled by the so-called hateful patient. Hate­ given by one whom the surgeon has not seen before. ful patients, according to Groves,18 are those with whom Moreover, if you have visited the patient and imparted the physician has an occasional personality clash, those the definite impression that you alone will be caring whom most physicians dread. "The insatiable de­ for him, you have established a covenant that morally pendency of hateful patients devolves upon a behavior should not be breached, merely because the subject that groups them into four stereotypes: dependent is unconscious and does not know of the dereliction. dingers, entitled demanders, manipulative help re­ An eloquent statement of the relationship between jectors and self destructive deniers." Unfortunately, patient and anesthesiologist intraoperative^ was these cliches carry the element of truth. "What the written by Suzanne Lamdin and published in ANES­ behavior of such patients teaches us over time is THESIOLOGY nearly 12 years ago. It is simply called, that it is not how one feels about them that is most "Poem."17 important in their case—it is how one behaves toward ROVENSTINE LECTURE 47

FIG. 8. A poor result in putting a patient to sleep.

"You ur<* ronipU'tely rclaxoil . . . u Harm feeling i« >rcii

When the practice of deliberate hypotension first came and perhaps, best of all, the furtherance of preventive under scientific scrutiny many years ago, John Gillies medicine. wrote on the subject of "Anaesthetic Factors in the Causation and Prevention of Excessive Bleeding References during Surgical Operations."20 Finally, there is con­ siderable merit to the plea for overall simplicity in the 1. Engel GL: The care of the patient: Art or science? John Hop­ kins Med J 140:222-232, 1977 conduction of anesthesia, which Noel Gillespie made 2. Goodfield J: Humanity in science: A perspective and a plea. over 31 years ago, essentially comprising professional Science 198:580-585, 1977 common sense and skill borne of practical experience. 3. Carson RA: What are physicians for? JAMA 238:1029-1031, Even then he was lamenting the modern tendency 1977 toward specialization, complexity and polypharmacy.21 4. Burnum JF: The malaise in internal medicine. Arch Intern Thus, I complete this analysis of some of the Med 137:226-229, 1977 5. Radetsky M: Recapturing the spirit in medicine. N Engl J ingredients that go into the making of an anesthe­ Med 298:1142, 1978 siologist-clinician, spiced here and there by my own 6. Regelson W: The weakening of the Oslerian tradition. The bias, as well as those of others. Our role in the practice changing emphasis in departments of medicine. JAMA 239: of medicine has been fashioned not only by historical 317-319, 1978 events but by the very nature of that practice, which 7. Thomas L: Notes of a biology watcher. How to fix the pre- medical curriculum. N Engl J Med 298:1180-1181, 1978 on superficial examination would seem to comprise 8. Moore A: Medical humanities—a new medical adventure. N only an abbreviated and narrow interface with surgical Engl J Med 295:1479-1480, 1976 patients. I plead that this need not be the authentic 9. Lister J: By the London Post. Silly-season thoughts. N Engl interpretation. Nevertheless, in many circles, we are J Med 297:921, 1977 classified with pathologists and radiologists as hospital- 10. Moliere's One-Act Comedies. Translated and with an Introduc­ tion by Albert Bermel. New York, Frederick Ungar Publish­ based physicians, as if to imply that the hospital base ing Co., 1962, ed. 2 precludes the pursuit of a humanistic brand of medicine. 11. Shaw GB: The Doctor's Dilemma. New York, Brentanos, I suspect that the confusion here relates to everyone's 1911 nostalgic recollections of the family practitioner, al­ 12. Rice NP: Trials of a Public Benefactor as Illustrated in the ways available to make the house visit. Furthermore, Discovery of Etherization. New York, Pudney and Russell, by no stretch of the imagination can one compare 1859 13. Salter WT: The leaven of the profession. ANESTHESIOLOGY the work of pathologist or radiologist to that of the 11:374-376, 1950 anesthesiologist, who holds the key, momentarily, to 14. Lortie DC: The sociologist looks at the profession of anesthe­ the survival of many kinds of patients, by reason siology. Anesth Analg (Cleve) 29:181-188, 1950 of intimate supervision of them and possession of an 15. Interim Report from the Committee on Anesthesia Survey. awesome pharmacologic repertoire. Despite my intro­ A.S.A. House of Delegates 1964 Session 16. Howat DDC: Anaesthesia as a career. Anaesthesia 32:979- ductory promise, I dare not attempt to predict the 995, 1977 future of our very special kind of endeavor. I am 17. Lamdin S: Poem. ANESTHESIOLOGY 30:2, 1969 convinced, however, that unless we strive to be clinicians, 18. Groves JE: Taking care of the hateful patient. N Engl we shall not attract to our guild the kind of individual J Med 298:883-887, 1978 that W. T. Salter or Dan Lortie had in mind. And 19. Shapiro RA, Berland T: Noise in the operating room. N Engl last, one might justifiably reflect that any of the J Med 287:1236-1238, 1972 medical specialties may experience a life and death 20. Gillies j: Anaesthetic factors in the causation and prevention of excessive bleeding during surgical operations. Ann R Coll of its own, because of developments in other fields, Surg Engl 7:204-221, 1950 the introduction of new species of drugs, the un­ 21. Gillespie N: Simplicity in anaesthesia. Br J Anaesth 22:192- raveling of the causes, therefore eradication of disease, 203,1950 -5- THE ROVENSTINE INHERITANCE — A CHAIN OF LEADERSHIP by S. G. Hershey, M.D.

SPECIAL ARTICLE

Anesthesiology 59:453-458, 1983

The Rovenstine Inheritance—A Chain of Leadership

Emery A. Rovenstine Memorial Lecture on the Occasion of the Annual Meeting of the American Society of Anesthesiologists

S. G. Hershey, M.D*

On occasions such as this, there is a sense of a lifetime thesiology, the super-specialist approach to patients at the compressed into a single moment. Can it be as many years cost of humane, personalized doctor-patient relationships, since, as a young intern, I was first interviewed by Dr. and a justifiable pride in our overall record of quality Rovenstine for an appointment to the resident staff at care. Last December Dr. Emanuel Papper, at the New Bellevue Hospital? Could as much have happened in the York Postgraduate Assembly noted, additionally, Roven- field of anesthesiology—to its clinical and scientific scope, stine's role in the development of anesthesiology as a to the men and women who have devoted their profes­ great and powerful movement throughout the world. sional lives to it, and to the societal and organizational Each of these well-developed themes, I am sure, struck framework in which our specialty functions, nationally a note of recognition and response in all of us. But in and internationally? The answer, of course, is yes, it has. choosing my own thrust, I decided to follow my instincts, The passage of time and the unfolding of destiny are based on the fact that when Dr. Blancato invited me, he both real and irrefutable and are brought home even said frankly, "You're among the last of the original Ro­ more deeply at landmarks such as this. venstine residents, you know." Disregarding the chill of Last January, when Dr. Louis Blancato called me to mortality this produced in my loins, I decided that, per­ invite me to present the 21st Emery A. Rovenstine lecture, haps this was a signal. This lecture should rightfully have I was deeply moved. I realized, of course, the high honor more emphasis on the personal—a human and profes­ being bestowed. The invitation also rekindled, almost sional evaluation of the man as well as the anesthesiologist immediately, memories of a relationship that was very we honor here, withall trying to avoid the sentimental special to me, which, in fact, influenced and shaped my pitfalls of nostalgia. The other decision was to focus on entire professional life. the concept of leadership, a quality that Dr. Rovenstine The preparation of this, the most prestigious lecture personified and passed on. A quality also shared by so in anesthesiology in this country, is a fearsome respon­ many of our colleagues whose talents and dedication have sibility. But I felt that somehow my long and always- enriched and will continue to shape the progress of anes­ stimulating association with Dr. Rovenstine would make thesiology. it possible for me to cope with this trust. Leadership—it is a word, an idea, and an ideal, both Previous Rovenstine lectures were all thoughtful and timeless and sharply contemporary. Ralph Waldo Emer­ discerning tributes to Dr. Rovenstine, and much, much son puts it into proper place "Life only prevails, not the more. Most of the distinguished lecturers in past years, having lived," he wrote. "Power ceases at the instant of you may recall, chose to take the Rovenstine legend as repose, and it resides in the moment of transition to a a springboard for voicing their concerns and satisfactions new state, in the darting to an aim." about the state and foreseeable fate of anesthesiology. Those who teach us, inspire us, who mold and direct The focus ranged from the quality of education in our our actions are enshrined in our memories when their specialty, the relevance and support of research in anes- lives are over. But their real contributions are measured by how they enlarge and change their fields in years to come, both by seeding and by example. Opinion and sentiment can create heroes. But the substance of their * Professor of Anesthesiology. Received from the Department of Anesthesiology, Albert Einstein true leadership is the use they made of themselves and College of Medicine, Bronx, New York. Accepted for publication how they transmit it to a new state. How their fire helps February 11,1983. Presented as the 1982 Rovenstine Lecture, October others to dart to a new aim. In our frame of reference 24, 1982, Las Vegas, Nevada. this would include first and foremost, improved care of Address reprint requests to Dr. Hershey: Department of Anesthe­ patients and clinical excellence. Next, the constant ex­ siology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, New York 10461. tension of the scientific bedrock on which anesthesiology Key words: Education: continuing. History: Rovenstine. is based, through research and education. Also, the drive

0003-3022/83/1100/0453 $01.10 © The American Society of Anesthesiologists, Inc. 453 S. G. HERSHEY Anesthesiology 454 V 59, No 5, Nov 1983 for increased stature in the medical and public world— he forged. I'm pleased to see a number of them here the latter a capricious world in which a seemingly in­ today. nocuous item noted in the mass media sometimes can Those of you of my generation in anesthesiology, or lead to unexpected consequences. thereabouts, are well aware of Rovenstine's key role in But first, let me begin with the personal. I had known the formulation of anesthesiology as a full medical spe­ Dr. Rovenstine in his early years at Bellevue when I was cialty, including its recognition as such by the entire med­ a third-year medical student. He had given our class a ical community. Interestingly, he also felt strongly that series of brilliant lecture-demonstrations in the famous the public, too, had to be made aware of the full and Stewart Surgical Amphitheatre at Bellevue. This expe­ special nature of physician anesthesia. To those who have rience had a great deal to do with linking my strong followed the ASA's recent public relations activities, it is interest in pharmacology to anesthesiology as a bona fide evident that Rovenstine was ahead of his time in rec­ clinical-academic specialty. I incidentally note with plea­ ognizing the need for such effort. In those years he did sure that so many of the scientific presentations at this this at some risk to himself. The roads he took did not annual meeting link many areas of pharmacology with always pass through friendly territory. Town-gown ten­ clinical anesthesia practice. sions were deeply rooted in many enclaves along the way. At the interview, which I remember as pleasantly brief, In one such instance, after he was featured in a series of Dr. Rovenstine finally said simply, "You can come to three low-key, informative profiles in the prestigious New Bellevue." Eighteen months later, just 3 weeks after Pearl Yorker magazine in 1947, a veritable hall of fame for Harbor, I started as one member of that very special current luminaries, Dr. Rovenstine was charged formally group known as Rovenstine Residents. Yes, it was 40 with unethical conduct—self-advertising. He was sus­ years ago that I had the good fortune to enter what was pended from membership in the New York County Med­ much more than a training program, but also an arena, ical Society and was asked to resign his membership in a showcase, a crucible—The Department of Anesthesia the New York Academy of Medicine. Today he would at Bellevue Hospital in New York. probably be a star on a cable network—those intense I call it an arena because even though it nourished dark eyes meeting audiences head-on and his Hoosier directness raising his ratings. Fortunately, this unhappy affinities, it was also a setting for the clash of assertive period of misunderstanding and contention is well in the young minds, and because there was a certain amount past. We all now recognize the importance of the public of jousting with surgeons and other medical colleagues image of anesthesiology and anesthesiologists. who had not yet awakened to this new brand of anes­ thesiology and this new breed of anesthesiologists. It was Even without Dr. Blancato's friendly reminder, I do a showcase, as well. Academic anesthesiology based on realize that the ranks of us earlier-vintage anesthesiologists clinical science as well as on clinical skill, was there to see who lived in the Rovenstine-Bellevue era are thinning. every day, a model for that time and for years to come. So that it is worthwhile to note a few of the salient facts And it was a crucible, a forging ground for many talents, of Rovenstine's colorful life and remarkable career to male and female, of many backgrounds. They knew they underscore the nature of the debt we owe to him as a were pioneers in a fledgling medical discipline seeking principal architect of our specialty. There is not time for the best. a full biography, but here are some of the actualities of Among those who had already been there before I his life and perspectives gleaned from many sources and arrived were John Adriani, Virginia Apgar, Charles Bur- from my own recollections. stein, Mary Lou Byrd, Stuart Cullen, Stevens Martin, Rovenstine was born and reared in Atwood, Indiana, Perry Volpitto, and Lewis Wright. Others were part of a town of 200 population, located in a farming com­ my time: Evelyn Apogi, Donald Burdick, Robert Dripps munity. He was the eldest of four sons. His family owned (not for the whole course), Austin Lamont, James Marin, the general store. The Rovenstine family work ethic was Emanuel Papper, and Frank Thompson. Somewhat af­ strong, as was their drive to self-improvement, traits he terwards, many still in uniform came back to study with diligently retained throughout his life. His work was his Rovenstine: Richard Ament, Sam Denson, George Finer, life. Human relations being what they are, there were Martin Helrich, Louis Orkin, Boardman Wang, and James times when those around him felt his consuming interest West. Many who had done anesthesia in the Army on in his work was the cause of some tragic events in his the basis of a 3-month crash course returned for short personal life. But this did not deter him. courses to update themselves. This was the start of for­ Rovey's childhood ambition was to be a school teacher, malized continuing education in anesthesiology, which, a goal he eventually achieved. He started his high school as some of you may know, is a field of medical education studies in Atwood, then transferred to a larger high school of special interest to me. All of these students of Roven­ in Blue Island, Illinois, where he lived with his uncle. He stine, today, are practically a roll of honor. They were was a good student, but probably a better athlete, playing part of his great plan—the links in the chain of leadership on his school's baseball, football, and basketball teams. Anesthesiology ROVENSTINE LECTURE V 59, No 5, Nov 1983 455

Oddly, it was his athletic ability at high school that for­ with anesthesia as a part-time specialty. Within a year he tuitously resulted in his much later entry into anesthe­ decided that he had to learn more about anesthesia if he siology training at the University of Wisconsin. During were to develop a larger and better-paying anesthesia his senior year, in the final quarter of a basketball game practice. It was then that Guedel arranged for his inter­ during which young Rovenstine felt that the referee had view with Dr. Waters. been in his way whenever he had the ball, he butted the When Rovenstine started his training at Wisconsin in referee in the stomach. The referee, a large man, picked 1930, the Wall Street Crash had just occurred and it was up the boy and spanked him. By chance, the referee, a the beginning of the Great Depression. Yet everything former athlete, was a physician on the faculty of the Uni­ was burgeoning in this still quite new, unique anesthesia versity of Indiana Medical School. His name was Arthur center that was to mean so much to the development of F. Guedel, none other than the distinguished anesthetist anesthesiology. Ralph Water's department was the model who first described the stages and planes of anesthesia. that pioneered the formation of separate, distinct de­ Years later, Rovenstine, when he became a medical partments of anesthesia at other medical schools. It also student at Indiana, reminded Guedel of the incident, provided a brand new framework from which today's which the older man had not forgotten either. Rovey training programs in anesthesiology evolved. Although and Guedel developed a special student-teacher rela­ Waters was primarily a clinician, he was probably the first tionship that continued after Rovenstine's graduation. academic chief-of-service to encourage and support lab­ And it was Guedel who arranged an appointment for oratory research that linked the basic sciences and basic Rovey with Dr. Ralph M. Waters at the University of scientists to the clinical art and practice of anesthesiology. Wisconsin. Thus, a low blow in a schoolboy basketball His own leadership is honored annually in the Ralph M. game led to perhaps the most significant single event that Waters Lectureship of the Midwest Anesthesiology Con­ launched Emery A. Rovenstine on his brilliant course in ference. anesthesiology. For five years, Rovenstine thrived at Wisconsin, clearly But let's fill in some years. After high school, Roven­ a favorite disciple of Ralph Waters. He had come there stine entered Wabash College on an athletic scholarship to perfect his knowledge and skills as a well-rounded cli­ and was graduated in 1917, just in time to enlist in the nician. But somewhere in the process he had become an Army Corps of Engineers for service in World War I. academic anesthetist, a career then only tentatively de­ He was sent to France as a Second Lieutenant and assigned fined. His interests, his knowledge, and his views widened to a courier detachment that brought him to the front greatly. His research capabilities were aroused and de­ lines. It was here, he felt, that he developed his first deep veloped. He spent much time in the animal laboratories interest in medicine, seeing and talking to the wounded with members of the Pharmacology Department studying and to medical corps personnel at ambulance pick-up various drugs. But it was his work with Waters on cyclo­ stations. propane that earned for him an early reputation. Rovey His interest in medicine, he would sometimes say, had the rare satisfaction of knowing that cyclopropane, somewhat tongue-in-cheek, was also hereditary. His often referred to as the "champagne of anesthetic agents," grandfather, a Civil War veteran, traveled between his was the most widely used, new inhalation agent during two farms in a wagon from which he sold a home-brewed his entire lifetime in anesthesiology—in fact, the most liniment that he claimed, with great flair and showman­ important new agent since the introduction of ethyl ether ship, could cure a long list of ailments. If Rovey inherited and nitrous oxide into clinical anesthesia, almost a century anything from his grandfather, it was a talent for show­ before cyclopropane. manship, which, while it never extended to snake oil ther­ In 1935, Waters was asked to suggest someone who apy, was evidenced in other ways. Once, at a New York could set up a modern department of anesthesia in the Academy of Medicine Graduate Fortnight, a prestigious medical school of New York University. He suggested annual event, he kept a dog anesthetized under water in Rovenstine, by now an assistant professor. The appoint­ a large fish tank to demonstrate the merits and safety of ment was offered promptly and accepted quickly. And, endotracheal anesthesia. Luckily the dog didn't drown. on New Year's Eve of 1935, Rovey, at the age of 40, left As for the technique, it also survived and its acceptance the Midwest for New York to begin his new assignment. is long years beyond question. It was both a tremendous challenge and the fulfillment Rovey, upon his discharge from the army in 1919, of a dream. To some of us he, at times, would recall his taught high school in Northern Michigan for four years. feelings about the importance of the Bellevue name and Then he gave up teaching for medicine. He entered the its world-wide reputation and his desire to establish a University of Indiana School of Medicine and took every first-rate department of physician anesthesia. His drive course in anesthesia Guedel offered. After graduation was always evident and his dedication to this purpose and a year of internship in Indianapolis, he returned to seemingly limitless. They all paid off—the Rovenstine La Porte, Indiana, where he set up in general practice era at Bellevue became a period of great importance to S. G. HERSHEY Anesthesiology 456 V 59, No 5, Nov 1983 anesthesiology in this country and, in fact, the whole hospitals, and, of no lesser importance, the professional world. agencies of anesthesiology—meaning, the American His achievements have endured as they have because, Board of Anesthesiology, the AM A Section and state so­ in the wisdom of his leadership, he shared his own de­ ciety sections on anesthesiology, and, of course, the velopments, his triumphs, his concerns, his insights with American Society of Anesthesiologists. the people around him. He was, in the purest sense, an Having conceptualized the masterplan for the second educator, for he knew from the beginning that, in William century of anesthesiology, Rovenstine did not retire to Osier's words, "No bubble is so iridescent or floats longer an ivory tower. Rather he labored tirelessly to build his than that blown by the successful teacher." He taught us Department and train his students in keeping with his well, and in doing so, insured the continuity of what he plan. And he became a prime mover in all the major had started, and helped to make education one of the initiatives affecting the civic and professional sectors of foundation stones of anesthesiology. our specialty. There is not time to enumerate all of his Insight into how Rovenstine viewed the state of anes­ causes, but two stand out. One is the American Society thesiology in his early years at Bellevue is provided ex­ of Anesthesiologists, so well represented in this room. plicitly in a talk titled, "The Development of Anesthe­ The other is the commitment to continuing education. siology," which he gave at the Annual Meeting of the Because neither have been accorded their full recognition Medical Society of the State of New York, later published in the overall scheme of contemporary anesthesiology, in the Society's journal in October 1942. Quite apart they sometimes fall between the cracks on occasions such from its message, this three-and-a-half-page article is a as this and deserve a passing note. good example of Rovenstine's elegant literary style and First, the ASA. Rovenstine was one of the two presi­ discerning grasp of the events that characterized anes­ dents of ASA to hold that office twice. He was a prime thesiology from its then century-old beginnings. In the mover in driving the Society towards its highest aspira­ article he deduced that, "The specialty has a favorable tions. In 1946 he was instrumental in moving the Society's position to approach its task of keeping abreast as medicine executive office from its rent-free, humble quarters in marches triumphantly on." Thus he indicated that the New York, staffed by a part-time secretary, to Chicago, time was right for anesthesiology to catch up and become then as now, the headquarters city for many of the major a bona fide, scientifically based clinical specialty with all national medical societies. He saw to it that a well-qual­ the trappings of the more established disciplines in med­ ified, full-time executive secretary was recruited promptly. icine. The article was also a masterful blueprint for struc­ This was a major step in the destiny of ASA. Today, this turing the second century of anesthesiology as it moved foremost specialty society stands as a tribute to the many, toward this goal. many members whose sense of collective responsibility The elements of his plan were simple and basic. His and whose wisdom have provided the continuing chain first priority was stated clearly. "The ultimate goal is the of leadership that is the core strength of ASA. patient's need, and whatever service may best supply it All of us know that this excellence springs not only with reasonable economy and convenience." How far- from our physician members. A good measure of the sighted this was of Rovenstine to pinpoint the factors that credit also must be directed to our talented and deeply later were to become the crucial issues of the health care appreciated Executive Secretary, John W. Andes, who community and the public, now called, quality, cost, and this year marks his 25th year with the Society. He has accessibility to health care. worked with all of us, often more than we realized, to Next, he believed, "The present need in anesthesia is make ASA the great society it is. I feel privileged, on this widespread, appropriate organization that favors the ac­ occasion, to ask for a round of applause to show, in some cumulation of knowledge and, of no less importance, the small manner, our recognition of Jack Andes' leadership, dissemination of knowledge acquired." In his view, the exercised so well in our behalf. element of education incorporated learning, research, And now to the second subject—continuing education, and teaching. But he expands on this theme, adding, one of the three major components of the educational "Moreover, it must be realized that the obligation to continuum in medicine, and as old as the practice of teach and to seek new knowledge is no greater than the healing itself. It is no news that ASA offered such post­ necessity of keeping intellectually fit to utilize and dis­ graduate education to its members long before continuing seminate knowledge." Again translating into the 1980s, medical education, some 20 years ago, was formalized we see the formal continuum of medical education rec­ into its present prominence in the life of the practicing ognizing, as never before, the necessity of lifelong profes­ physician. It would serve no purpose to rehash the litany sional education. I'll say more on this subject a bit later. of the pros and cons, whys and wherefores, and intro­ In the same article and in other of Rovenstine's writings, spective searching surrounding CME to this sophisticated he points out that these evolving changes should be de­ audience. Suffice it to say that anesthesiologists, almost veloped from within the organization of medical schools, universally, believe in the importance of continuing ed- Anesthesiology ROVENSTINE LECTURE V 59, No 5, Nov 1983 457 ucation, and through the ASA, support and voluntarily goals—the benefit of patient care. I'm not at all certain participate in its extensive, well-organized program—one of the need to expend the time, energy, and money re­ of the best in any national specialty society. Thus, we quired to grapple with these arbitrary questions. I believe demonstrate that lifelong learning is no longer an option. that the formalized structure of the "new continuing It is a vocational and ethical necessity. medical education" should be designed and utilized within The crushing accumulation of new knowledge, the the framework of what it essentially is, namely, a means fragmentation of once-simple issues, and the remarkable more effective than earlier means for accelerating and advances of technology-based clinical management greatly facilitating the acquisition of new knowledge and tech­ have sharpened our awareness of this need. As a result, niques for sound clinical application. there is a new air of excitement in the continuing edu­ Nor should continuing education be mandatory. The cation component of professional education. This is prob­ required documentation of a specified number of ably the basis of my own involvement and lies behind the "brownie points" is no assurance of physician competence. direction of my time and effort in the Society's educational This credit-accumulation process, inevitably, has become activities. This interest and its many dimensions have been a new type of adult game, which, just as inevitably, de­ a source of much satisfaction throughout the years. And means our profession. Given the physician's basic moti­ perhaps, the most satisfying has been the .AS/4 Refresher vation to practice up-to-date medicine, this incentive will Courses in Anesthesiology, the publication creatively con­ be best served if the educational means to do so are rea­ ceived by Dr. Siker, and that I edit along with Drs. Betty sonably accessible at reasonable cost. And, most impor­ Bamforth and Howard Zauder. As it celebrates its Tenth tant, if the student-teacher relationship in the conduct Anniversary volume this year, there is reassurance in the of individual educational exercises supports rather than fact that this is the most successful annual publication in deflates the physician's self-esteem. anesthesiology, thanks to the talented members of the What projections for the future are in view? For one, Society who have contributed to its excellent contents. there will be increasing emphasis on self-directed learning What is the present state of continuing education? And oriented toward clinical problem solving. Physicians, on how is it likely to change in the next 20 years? One can a formal basis, will be offered guidance in the art of self- prophesize by reading literature and following trends. learning. Stripped of educator jargon, this approach will But one is finally dependent on one's own accumulated accelerate and facilitate the use of new knowledge in hunches and built-in crystal ball. clinical practice. In such context, this approach also re­ Continuing medical education, most people will agree, duces the perceived threat of technology to the physician's is in a state of considerable confusion and disarray. Despite traditional role and responsibility in clinical decision the fact that there is general agreement that it is here to making, thus contributing to personalized patient rela­ stay, almost every aspect of its formulation and delivery tionships. is in question. There are vacillations, well-meaning, but The second projection is already discernible. The major still indecision on identifying curriculum needs, criteria national specialty societies, like The American Society of for evaluation, and on questions of content and emphasis. Anesthesiologists, will provide the largest volume of con­ We face a scenario of noncoordination based mostly on tinuing education to the medical profession. This is a differing and oscillating points of view among the various significant relocation resulting both from marketplace agencies of organized medicine. Shall continuing edu­ factors and emerging civic forces. Why is this likely? All cation be mandatory? And for what constituencies of of medicine today is practiced within the officially des­ medical practice? For revalidation of our license to prac­ ignated disciplines of the various medical specialties. And tice? For maintaining board certification in good standing? each has its own dedicated organization and its own built- For continued membership in major specialty societies? in postgraduate student constituency. Thus, they are un­ Or for retention of hospital staff appointment? How much derstandably closer and more sensitive to the interests of education? What modes of its presentation and what scope their members than other, more broadly-based continuing of its content are necessary to retain professional com­ education provider groups and institutions. These soci­ petence? Is 50 hours per year the magic number? And eties also automatically incorporate, within their own how is this time to be allocated in the six categories of membership, the best-qualified and largest faculties in credit? What subjects are or are not acceptable based on the nation to teach their own special discipline, and at their relevance to practice? And most problematic, how the most reasonable cost. Because of such natural selec­ is individual learning to be verified? By written exami­ tion, each society can respond to its members' needs— nation, practical examination, peer review? Or, as is cur­ and yes, often demands—in many areas. They will con­ rently trendy, by self-evaluation based on confidential centrate increasingly on continuing education. The reality examination, or simply by personal decision. And yet, of this trend is evident. We are already seeing a con­ despite all the uncertainties, it is clear that continuing traction in the number of continuing education offerings education is moving effectively towards its fundamental by the medical schools and other organizations. I con- Anesthesiology 458 S. G. HERSHEY V 59, No 5, Nov 1983 fidently predict that the ASA will continue to be a leader As I come to the close of my remarks today, I return in providing for the ongoing educational needs of anes­ to the man in whose name this lecture is given. What thesiologists. lesson, if any can be learned from the life of this unusual Lastly, we face the implications of what has been called man? I have myself learned a lesson in the preparation the communications revolution, or the age of electronic of this talk, and I hope you have shared my feeling of information, which may indeed change our professional encouragement that he has left us all a valuable legacy. as well as our personal lives. Nowhere in the field of Dr. Rovenstine's extraordinary achievements were education will the change be more evident than in con­ made possible, at least in part, because of the opportunities tinuing education to which the many new technologies at his time and at his place. Others may have been there are so applicable. There are the various linking and in­ too, but he had the skill, the dedication, and the enthu­ teractive types of cable television, already a reality. Data­ siasm to grasp the chance he was offered and make it base types of computerized information networks are very meaningful. Opportunity is not limited to any given time much with us. The American Medical Association has in the ceaseless development of medicine. Each period already inaugurated such a nationwide electronic network in every generation has different challenges. Many are last month called AMA/NET. This system eventually lying there, scattered on the open ground, and passed can permit printouts for individual home use. Self-con­ by. Others must be self-conceived and developed with tained, microcomputerized technologies, which are courageous and revolutionary thinking. largely portable, and can function anywhere at anytime, I have already spoken on technology as part of con­ working from tapes, videocassettes, or videodiscs also will tinuing education. Apart from that, we all know that we become part of our learning and teaching routines. still do not have the ideal, or even nearly ideal, general Such technologies may, in large measure, ultimately anesthetic for regular clinical use. It is conceivable that replace the live lecture. And at future dates an ASA the mind-boggling advances in neuroscience, elucidating conference may be satellite-beamed to five or more cities the intimate functioning of the brain, could be directed instead of one. Meanwhile, however, the traditional me­ to the perennial search for a more nearly perfect anes­ dia—books, journals, newsletters, closed circuit television, thetic modality. Conversations many of us have had with and film—also will continue to be used generously as electronic physicists and engineers have indicated that modes of delivering continuing education. Admittedly, the state of this science, if assiduously applied, could very it sometimes seems advisable to resist the new technologies likely antiquate current patient monitoring procedures. for continuing education as a stifler of human contact The development of information-science technology and individualized learning. But this is as foolish as in­ stands ready to increase, infinitely, our ability to docu­ sisting that we should all have come to Las Vegas by horse ment, to understand and to make critical judgments vir­ and wagon. It is no high-technology freak dream that tually on-line. Electronic anesthesia as in science fiction the day may come when the whole of continuing education movies? It was explored several decades ago, unsuccess­ will be linked together by computer intelligence, on line, fully. Maybe this science now is sufficiently advanced to with instantaneous, interactive exchanges of information. reexplore its possibilities. However, it is unlikely that computers ever will replace There are lessons to be learned from the past and the physicians. But they can and will assist as expert consul­ present for the future. There are leaders in this room tants. The ultimate decision requires personal, subjective who will, down the pike, possibly have their name on considerations and still will rest with the clinician. I do memorial lectures, though, hopefully, not soon. And there not foresee anesthesia robots. are young men and women who may feel that their world What is more likely is the use of the old and the new is not as full of opportunities and open doors as it was for comprehensive and more effective continuing edu­ in the early days. They are wrong. There is a quotation cation. The integration of electronics will take consid­ from the ancient Hebrew Talmud which seems oppor­ erable time to invade the judgmental world of daily clinical tune: "In every age there comes a time when the lead­ practice and should not be seized on just because they ership suddenly comes forth to meet the needs of the are new. We should meet the challenge of this future hour. And so there is no man who does not find his time, gladly, as a great opportunity. Record keeping and data and there is no hour that does not have its leader." collation already are being revolutionized. But we should For the better part of the last hour I have pictured a move carefully among our options to those systems that leader who dominated his time in anesthesiology and who best support us in our basic mission—the highest quality began a chain that extends into this room and into all anesthesia care of patients. When the chips are down, our professional lives. He helped to make our specialty and I use the word in all its modern connotations, that's great. It is up to us, and especially to our newest, youngest the vital question. members, to carry on in equally inspiring tradition. -6- CARDIOVASCULAR ANESTHESIA: Perceptions and Perspectives by Arthur S. Keats, M.D.

SPECIAL ARTICLE

Anesthesiology 60:467-474, 1984

The Rovenstine Lecture, 1983: Cardiovascular Anesthesia: Perceptions and Perspectives

Arthur S. Keats, M.D. *

THIS LECTURE is to honor the memory of Dr. Emory lecturer reveals himself, in a literary sense, his attitudes, A. Rovenstine. I have little to add to the lore of Dr. thoughts, and the style with which he handles the chal­ Rovenstine, since I only met him once and that was in lenge. The audience in its part is like a first night audience my sophomoric phase of development. It was at the New and critiques the performance. With this view I reflected York Postgraduate Assembly about 1949 when I was a on several aspects of my professional career and elected resident in Beecher's program, presenting a paper in the to talk about cardiovascular anesthesia. I made this choice Assembly Residents' Program and he was at the peak of because, by chance, I have had a rather extraordinary his popularity. In the Beecher program, cyclopropane experience in this regard. It was extraordinary because, was considered a chemical warfare agent. Diethyl ether first, my continuous direct involvement in cardiovascular was the only safe anesthetic, as everybody should have anesthesia for what will soon be 30 years. Second, it was known, and Dr. Rovenstine was the arch enemy who extraordinary because of my close association with two advocated poison gas. The only cyclopropane tank at phenomenal surgeons, phenomenal as people as well as Massachusetts General Hospital was locked in the bomb surgeons and explosive in their interaction. Blessedly, shelter. Only Bernard Briggs was permitted to use it and one of these associations came to an end at just the right only for patients with myasthenia. After I presented my time. And finally, it was extraordinary because I had this paper, my fellow residents and I adjourned to the lounge experience in the dynamic and economically flourishing of the New Yorker Hotel, where Dr. Rovenstine and a environment of Houston, where it was refreshing to find group of his admirers also were enjoying themselves. I that tradition began at the end of World War II, where was dared by my fellow residents to approach the enemy precedence began with whatever happened each, day and and ask some provocative question about cyclopropane, where a small ranch outside town in 1955 made one a beginning with "Dr. Beecher says. ..." Feeling very downtown landlord today. well at the time and being very juvenile, I took the dare, I looked over these years and made some observations and after working my way into his group, I lost my nerve that I will share with you. I call these observation per­ completely, such was my imagined emotional content of ceptions when they simply reflect historic observations, the cyclopropane issue. When the time came to introduce and I call them perspectives when these observations rep­ myself, I said I was a shoe salesman. All I can add to the resent a configuration that may have relevance to future lore of Dr. Rovenstine is that he was very kind to itinerant practice. shoe salesmen from Boston. The bad news is he never The major stimulus to attack diseases of the heart by bought me a drink. surgical therapy was a product of World War II and the The honor that devolves on the person selected to give experiences in successful repair of wounds of heart and this lecture is apparent from the distinguished lecturers blood vessels. It began with operations on the great vessels who preceded me. Like my predecessors, I am sure, I near the heart, then to blood vessels elsewhere in the am urged to respond to the honor in kind and deliver body, then to closed methods for diseases within the heart, some words pregnant with new insights and revelations. and culminated in successful open heart operations in That will not happen, of course. There are simply not the mid 1950s. enough revelations to go around these days. Instead I Looking at today's great interest in cardiovascular view this lecturership as a brief showcase in which the anesthesia and looking at the dates of references in articles concerning cardiovascular anesthesia, one almost could

* Clinical Professor of Anesthesiology. believe that cardiac surgery started in 1970 with coronary Received from the Division of Cardiovascular Anesthesia, Texas artery bypass grafting, with the invention of morphine Heart Institute, P.O. Box. 20269, Houston, Texas 77225. Accepted anesthesia, and the introduction of the Swan-Ganz cath­ for publication November 2, 1983. Presented as the 22nd Annual eter. Did anything at all important happen before then? Rovenstine Memorial Lecture, American Society of Anesthesiologists, October 10, 1983 Atlanta, Georgia. As an antidote, I take pleasure pointing out the fre­ Address reprint requests to Dr. Keats. quency by year of open-heart operations at the Texas

467 468 ARTHUR S. KEATS

-Middle Period y Late Period- r-Current Period

55 56 57 58 59 60 61 62 ' 63 *64 ' 65 ' 66'67 ' 68* 69 " 70 ' 71 '72 ' 73 ' 7* ' 75 ' 76 ' 77 ' 78 ' 79 80 81 ' 82 ' 83*

CD NON-CORONARY WM CABG * PTCA

FIG. 1. Open-heart operations per year at the Texas Heart Institute 1955-1982. Abscissa is calendar year; ordinate is number of operations. CABG = coronary artery bypass graft operations. PTCA = percutaneous transluminal coronary angioplasties. Actual number of open heart operations per year is noted at each histogram level.

Heart Institute during the years of my involvement with onary angiography, which made it possible to know which cardiovascular anesthesia and surgery (fig. 1). The early arteries could and should be bypassed. No one should period was largely limited to congenital defects in children forget the pioneering efforts of Beck and Vineberg in and the number of operations plateaued. The surge of the surgical treatment of coronary artery disease and the the middle period was attributable to the availability of unsung, and to me unknown, persons who successfully prosthetic valves, disposable oxygenators, and use of crys­ anesthetized their patients with coronary artery disease talloid solutions for priming the oxygenator. Then this far sicker than the ones we meet today for operations plateaued. The late period is attributable to coronary far less successful than bypass grafting. artery bypass grafting, which now accounts for about My first perception, then, is that there were, and are, 65% of our operations but I suspect better than 90% in many unsung heroes among us and the ones who are many other hospitals. We are now in another plateau known deserve to be recognized as such. Some are special period of about 5,000 open-heart operations per year heroes to me because they wrote about their experiences depleted by the number of percutaneous coronary an­ and provided me the only guidance available in 1955. gioplasties done each year, a procedure whose value re­ Among those who wrote, I specially wish to salute a few. mains to be determined. Obviously the great current in­ First, I salute Merel Harmel and Austin Lamont, who terest in cardiovascular anesthesia arose from the explo­ published in 1946 the very first article about anesthesia sion in coronary operations during the 1970s, an explosion for cardiac operations. It concerned the first 100 patients justified because of its high success rate in relieving symp­ on whom a Blalock-Taussig shunt was attempted with toms and increasing longevity. This high success is in part remarkable success. The article is a pleasure to read in because it is a technically easy operation without many its ingenuousness, its candor right down to their inability of the potential complications of other open-heart op­ to find the right size endotracheal tubes and connectors erations. for infants, and its complete account of all their troubles. As a further antidote to believing that it all started in This article that I found so rewarding in 1955 wouldn't 1970,1 take pleasure in reminding you that the principles have a chance of getting published today. required to perform this operation (extracorporeal cir­ I salute William McQuiston, who worked with the sur­ culation and bypass grafting) were established long before geon Willis Potts at Children's Memorial Hospital in Chi­ the operation was introduced in 1967 and this operation cago. Dr. McQuiston must have been a superb clinician. became possible only through the development of cor­ Based on reason alone, he introduced surface cooling of Anesthesiology PERCEPTIONS AND PERSPECTIVES 469 V60, No 5. May 1984

hypoxic cyanotic children to decrease oxygen demand TABLE 1. Conceptual Landmarks in CV Surgery before 1960 and introduced controlled respiration with cyclopropane Vascular Cardiac to facilitate the delicate anastomoses required. I also salute Kenneth Keown, not only for his extraor­ Segmental occlusion Defibrillation Homograft grafting Electrical pacing dinary equanimity in facilitating the innovative operations Prosthetic grafting Hypothermia and circ arrest of the colorful Charles Bailey, but for devising a method Bypass grafting Extracorporeal circ of anesthesia for patients with end-stage mitral valve dis­ Reversible organ ischemia K+ Cardioplegia ease that permitted the use of cautery. His method in­ Heparin-protamine action Hemodilution cidentally consisted of intravenous procaine, thiopental,

decamethonium, and N20. Finally, I salute John O'Donnell and Tom McDermott 10 years, so it was in this golden era (table 1). I do not of Georgetown University, who in 1953 somehow were imply nothing has happened since 1960. Obviously so able to get most of their patients with wide open aortic much is better now than 25 years ago. But to a large insufficiency to survive cross-clamping of the thoracic extent the great improvement is not because we have aorta for insertion of a prosthetic Hufnagel valve into become so much smarter or more skilled, but rather be­ the descending aorta. cause of what industry and technology have done for us These men, and many I did not mention, including in providing better tools, materials, machines, and drugs. many who were contemporaneous with me, were heroes Let us give them their due. because of their courage to face new challenges without In looking back over what has happened since 1960, guidance or precedence, without sophisticated monitors it occurred to me that it might be more educational to or equipment, and with only their intelligence and clinical reflect on what has not happened in these intervening acumen to contribute to the surgical outcome. They were years, rather than what did. And this led to some other encouraged by an extraordinary group of surgeons who perceptions (table 2). First, some serious problems we had had even more courage, together with imagination, vision, were never solved; they just disappeared. For example, skill, and determination. Together they provided a unique the homologous blood syndrome, which probably was era in the history of anesthesia and surgery. some form of disseminated intravascular coagulation, the These were times of high excitement, a golden era. pump lung syndrome, which probably was microembo- Almost every operation was a new experiment and every lization, and postperfusion renal failure, probably mi- experiment was relevant. There were no animal models croembolization as well. The mechanisms of these com­ for the diseases treated, no alternative therapies, and no plications never were discovered; they simply disappeared Human Experimentation Committees. The diseases were when crystalloid replaced blood alone as the prime for essentially incurable, many with fairly predictable high the oxygenator. mortality. The downside risk was small. To try was better Then there were the serious problems that were not than to do nothing, if one had patients with courage and solved and never went away. For example, the prevention faith to undertake unknown risks and if these patients' of air and particulate embolism during open heart op­ own physicians had the courage and vision to recommend erations, the prevention of stroke after carotid endar- untried therapies. terectomy, and the prevention of paraplegia after thoracic Against this background of high mortality and incur­ aneurysm resection. These problems led to what I call able disease, success was measured easily in terms of sur­ circus movements. A circus movement describes what vival with a corrected mechanical defect. Like penicillin happens when after trying all variations on a theme and for pneumonia, one didn't need controls to determine finding none of them work, you end just where you success. One day's experiment in the operating room led started. There is no better example than carotid end- to a new one the next day. Progress was made primarily arterectomy, which began with local anesthesia on awake by empiricism, by trial and error. All this generated the patients with trial occlusion of the carotid to determine high excitement and the feeling that there was so much the need for a shunt. This was replaced by general anes­ to do and so much to learn. At one time, I remember thesia with a shunt for all patients, then general anesthesia we thought we needed to add one more member to our team, someone who would just sit in the corner and think; there was so much new going on. TABI.K 2. Nonhappenings Since 1960 Another perception I have is that most of the important A) Serious problems not solved; disappeared conceptual advances in cardiovascular surgery occurred B) Serious problems not solved; not disappeared during this early golden era in the 1950s. Like a new C) Serious problems not solved; not problems departmental chairman who accomplishes 75% of all he D) Significant contributions abandoned E) Significant contributions not generally appreciated will accomplish in the first five years and 95% in the first 470 ARTHUR with hypercarbia and no shunt, then a shunt only if in­ knowledge. I will give just two examples. The first is ternal jugular oxygen saturation was low, then only if ischemic cardiac arrest. We continue to view the heart stump pressure was low, then only if the EEG changed, as a supremely sensitive and delicate organ that must be then only if regional blood flow was low. No method protected carefully during anesthesia. Yet during all the successfully prevented all strokes. I understand surgeons years before cardioplegia, one could cut off its blood now are returning to local anesthesia, awake patients, and supply completely for at least 1 hour at normothermia trfal occlusion. This is a complete circus movement. One and expect almost full recovery after several minutes of can describe a similar circus movement in prevention of reperfusion. The heart is in fact a very tough organ, and paraplegia after resection of thoracic aneurysms. Circus when it malfunctions, we simply cannot look to a brief movements strongly suggest to me the original premise period of ischemia for its failure. was wrong and the wrong question was asked. I believe Another better example is extracorporeal circulation these problems will be solved only when a new hypothesis with hemodilution. To me this is the most remarkable is proposed and the right question asked. experiment in humans. For more than 20 years, we have Then there were a large group of problems that were primed our oxygenator with crystalloid alone, producing perceived as serious but never were solved. For example, acute hemodilution with a hemoglobin of about 7 gm% high flow versus low flow perfusion. Which is better? What and perfused patients at normothermia with a low cardiac is the optimal perfusion pressure or safe perfusion pres­ output of about 3.5 1/min. Under these circumstances sure? What is optimal heparinization? The ideal priming anesthetized patients are perfectly well oxygenated and solution? Which oxygenator is better? And now, what is perfused at a mean blood pressure of 40-50 mmHg. The the ideal cardioplegia solution? Despite tens of thousands brain is perfused adequately, the liver doesn't fail, and of dogs, endless experiments and papers, there are no the kidney continues to produce urine. Hemodilution is clear answers. In my simplistic way, the reason there are the important reason it works because as hematocrit de­ no answers is because they are nonproblems. Either it creases, so does viscosity, which decreases resistance to makes no difference or the difference is so small as to be flow through small blood vessels. This means that pressure unmeasurable at present in terms of outcome. is lower at the same flow or flow is higher at the same On the other hand, some of the good things done in pressure with no change in caliber of the resistance vessels. these early years were abandoned because of the empiric Most significant is that in acute hemodilution the large nature of the progress at the time and because there was increase in cardiac output is a passive phenomenon and so much else to do. The best examples were potassium not the result of increased cardiac work. This relationship cardioplegia, which was worked out completely in prin­ seems to have escaped most anesthesiologists, who prob­ ciple in 1958 but completely abandoned by I960, and ably worry more about pressures and flows than anyone deep hypothermia with circulatory arrest, which was else. Is there anyone here who corrects observed blood started and abandoned twice and is now again in vogue. pressure for viscosity, that is, the hematocrit? Isn't it I often wonder what other good ideas were tried and meaningful that polycythemic patients with vascular dis­ abandoned or not even tried during those heady years. ease when bled and hemodiluted have a lower blood pres­ For example, because of blood requirements and early sure, with fewer transient ischemic attacks, less inter­ problems associated with extracorporeal circulation, ev­ mittent claudication, and even angina? Does anyone eryone tried to minimize the volume of blood perfused. equate optimal filling pressures, optimal perfusion pres­ Some talked of using reversible metabolic inhibitors to sures, or safe limits of hypertension or hypotension with allow minimal perfusion. Others tried hypothermic per­ hematocrit? Or will we just keep teaching our dogma of fusion of the brain alone to minimize the perfusion vol­ autoregulation being lost at some magic number and this ume. We once had the great idea of perfusing the body number should not be exceeded whatever the hematocrit? core only, and I built a system of cuffs that inflated si­ Somehow this extraordinarily important physiologic fact multaneously to shut off" the circulation to both arms and has not been integrated into our practice and generally hopefully the abdominal aorta. We tried it on a young is not accepted as applying, except to patients who un­ boy of about 100 lbs. The only difference we noted after dergo extracorporeal circulation. This is probably because inflation and perfusion was that he developed an erection. anesthesiologists never were really involved in the de­ The device became known as the Love Belt, achieved velopment of extracorporeal circulation and frankly don't great local notoriety and a few late night phone calls. I feel comfortable with it. now regret at my age that we moved on to the next So far I have been talking primarily about surgery. experiment. Where was anesthesia all this time? Not idle. Anesthe­ Finally there were events I regularly observed that siologists were responding to the new challenges of these seemed so remarkable to me but whose significance has operations but in exactly the same empiric fashion as did never been fully incorporated into general medical the surgeons. For example, early on, cyclopropane sup- AnMtliniolngv PERCEPTIONS AND PERSPECTIVES V HO. No 5. Mav 1984 471 planted ether for operations on chijdren because of the TABLE 3. Surgery for Patients with Heart Disease breath holding and struggling during induction in babies 195.") 1975 already cyanotic from inadequate pulmonary blood flow. In adults the importance of light anesthesia was apparent 1) Too sick to operate 1) Too sick not to operate early to prevent further depression of failing hearts and 2) Local is anesthetic of 2) Too sick for local. choice. Too sick for General is anesthesia led to the use of curare and morphine during operation general choice with controlled ventilation. Halothane became important 3) Give digitalis and 3) Discontinue because it was not flammable with all the new electric quinidine preoperative digitalis preoperatively and quinidine devices entering the operating rooms. Succinylcholine 4) Discontinue 4) Continue preoperative became important as a substitute for curare, which preoperative antihypertensives, Beecher had convinced surgeons'was killing their patients. antihypertensives, etc. Monitors and mechanical ventilators became available and etc. 5) Give norepinephrine to 5) Give vasodilator to the need for intensive care units became obvious to permit increase blood decrease blood ventilation to continue postoperatively. Did any of these pressure and pressure and changes make a difference? One would think that in such coronary flow coronary flow 6) Restrict salt and fluids 6) Give abundant lactated a high-risk group it would be easy to tell. But that was Ringers not so. In terms of improving operating conditions for the surgeon and thus allowing him to do his job more easily and perhaps better, yes, they made a difference. numbers of patients. Therefore we have to depend on Did these changes affect outcome? Did more patients sur­ logic." Unfortunately, his statement epitomizes current vive? We still don't know. The number of patients were attitudes. Unfortunately for his premise, if you live long too few and surgical mortality too high to distinguish enough you recognize the logic he refers to changes each between the effects of better anesthesia or better oper­ decade (table 3). When I pointed out the nonhappenings ation or the simple benefits of experience. since 1960, I remarked on circus movements, that per­ This perception leads me to my first perspective, which ceived problems turned out to be nonproblems, and im­ is that our inability to measure the effects of changes in portant advances were abandoned. How can we be so anesthetic agents or techniques on the outcome of op­ sure today's logic is better than that of the last decade eration is one of the great pressing problems in our spe­ unless we measure some aspect or index of outcome. cialty. At a time when we have three fluorinated hydro­ That mortality rates fall and everything seems better may carbons for inhalation, at least three intravenous induction only reflect the so-called "practice effect," the more times agents, three narcotic supplements, five curares, and are you do it, the better you are in doing it. And maybe this threatened with the introduction of more of each, we alone is responsible for the better logic that comes each have no method for determining whether any one is better decade. or worse than another in terms of outcome. The logic referred to in that quotation is the concept It seems silly to remind this audience that the purpose of normality, the concept of the ideal anesthetic agent, of anesthesia is to facilitate a surgical therapy and that a which does not do any thing to any body function except better anesthetic is one that enables the surgeon to do produce insensibility. The logic says normal is better than his job either better or faster or cheaper or is one as­ abnormal and the newer anesthetic agents are better be­ sociated with lesser morbidity or mortality or hospital cause they are less disruptive of normal or in advertising stay or lesser cost. We hardly ever attempt studies of terms, they provide greater "circulatory stability." outcomes any more. The only large-scale studies directed This concept of normality makes us feel better. After to this end in this country were the Beecher-Todd death all, who can blame us if we keep everything normal, espe­ rate study and the National Halothane Study, now almost cially if the values used are awake normal, not even anes­ 20 years old. Without studying some aspect of outcome, thetized normal. The concept may satisfy our need to how will we ever know if isoforane is better than halothane rationalize our inability to measure outcome in the sense

or not as good as Demerol-N20? The lack of outcome that we can measure normality and we can compare agents studies, that is, the demonstration that something is better and find greater or lesser deviation from normal values. or worse than something else in terms of therapeutic This is just what we do now. But if we are going to be objectives, has, to me, two unfortunate consequences. honest, we don't even have data to show that normal is The first is the substitution of the criterion of normality better than abnormal in terms of outcome, except in the for measurement of outcomes. At a recent meeting I very extremes of abnormality, because no one has mea­ attended, one of our more vocal cardiac anesthesiologists sured it. Of course, one can invoke the logic of DeBakey, said, "Outcome has become the buzz-word pf this decade. who was never bothered by high blood pressure, but But outcome studies are difficult to do and require large emotionally could not handle low blood pressure. A dis- Am-»lli«-«iilnny 472 ARTHUR S. KKAIS V 1)0, No 3. M.iv M1H4 cussion of this issue with him, which usually consisted of of error proof machines should be given the highest 10 minutes of listening, always concluded with "After priority in the interest of public health and, incidentally, all, dead people don't have blood pressure." A real con­ of self-destruction. versation stopper. There is a second important perspective I gained from Normality is not tantamount to virtue. Low body tem­ watching the development of cardiovascular anesthesia. perature is at times better than normal, very huge doses I will call it the role of environment in the outcome of of thiopental may be better than small doses, low he­ operation. Roy Vandam wrote about this many years ago moglobin may be better than normal hemoglobin, and, and was rewarded with overwhelming indifference. It is under some circumstances, abnormally high systemic vas­ perhaps the environmental factors more than any other cular resistance may be life saving. Being anesthetized is that make it so difficult to measure the differences in not normal, nor is being operated upon, nor being per­ anesthesia outcome I just alluded to. By environmental fused extracorporeally, nor having the blood supply to factors, I mean all the measurable and unmeasurable as­ organs temporarily cut off. Keeping everything normal pects of anesthesia and operation. Drugs, techniques, du­ may keep us blameless, but it may not be the best patient ration, and monitors can all be measured; but there are care. attitudes, skills, emphasis, interactions, and, particularly, We must at least entertain the possibility that normality timing, these are the unmeasurable. That they exist and may not be the best, that abnormal values of something operate in outcome is unequivocal from the differences may be better during anesthesia, and most important, in institutional death rates of the National Halothane whether it makes any difference either way on the out­ Study and the differences in institutional death rates of come of the surgical treatment. If none of this makes a the collaborative Coronary Artery Surgery Study. difference, then the least costly way of doing things be­ Nothing could be more disparate than the forms in comes the best. As an example, one need only look at which open heart surgery developed almost simulta­ the silly gyrations anesthesiologists went through before neously at the University of Minnesota and Mayo Clinic: agreeing to anesthetize anemic uremic patients for renal one, with a crude bubble oxygenator that barely pushed transplantation, all because of their commitment to nor­ blood around; the other, with a highly efficient complex mality. one that profused rather than perfused blood. Yet the The second unfortunate aspect of the lack of outcome result, the outcome, of both methods was equally suc­ studies is the idea that the choice of anesthesia makes no cessful. Nothing could be more disparate than the surgical difference since when you get right down to it, we have philosophy, attitudes, and emphasis of DeBakey and no information to show one choice is better than another. Cooley, yet both achieved extraordinary success in their We have, in fact, precious few clear indications or con­ surgical outcomes. Each institution that eventually got traindications for specific drugs or techniques. Try making involved in cardiovascular surgery gradually evolved its a list starting with not giving succinylcholine to burned own magic for success, and they were all different in the or traumatized patients. See if you get past 10 clear cut many ways they did things. Conversely, in the early years, well-documented indications or contraindications. many institutions were unable to mount a successful open- This is why the operational premise in the oral ex­ heart program, even though they thought they duplicated aminations of the American Board of Anesthesiology is precisely all that was done in a successful program. that the choice of anesthesia makes no difference if you Each saw something else as the reason for success or lack can defend it. You can choose spinal anesthesia with in­ of it. tubation for thoracotomy, since no data show the outcome In our institution in the early days, we had many visitors is any worse than general anesthesia. For the same reason, who were planning their own open-heart program and the American Board has never been able to construct wanted to see how we did it. If the visitor were a surgeon, patient management problem questions because there are he attributed all our success to the high quality of anes­ no data to support the right and wrong choices necessary thesia. If the visitor were an anesthesiologist, he concluded to construct this kind of question. he would have no anesthesia problems if his surgeons We are in fact back to where we were 40 years ago. were like ours. We all look, but what do we see? Although "Patients don't die from anesthetics only from anesthe­ these aspects of surgical care are virtually unexplored in tists. It doesn't make any difference what drug you use, terms of identification and quantification, I believe these if you don't make mistakes." If this is indeed true, then as yet unmeasurable environmental factors affecting out­ anesthetic drugs are different from all other known drugs, come constitute a major reason it is so difficult for us to and we don't need any more new drugs. We should take know what is right, what is best. Until we can identify advantages of this uniqueness and build error-proof ma­ and measure these aspects, we must accept that each in­ chines to supplant error-prone anesthetists. In the absence stitution has its own magic of good and best, that high- of outcome studies and with a normality logic, the building dose fentanyl may be a panacea in Toronto, but frankly PERCEPTIONS AND PERSPECTIVES 473 noxious in San Francisco, that Swan-Ganz catheters may TABI.F. 4. Citations to and Citations by be life saving in Atlanta, but mostly a nuisance in Houston. ANKSIHF.SIOI.OGY 1978-1982 It is an error to assume, without hard data, that my way is better or worse than your way because of logic, par­ ticularly the easy logic of normality. Citations/yr = 5,524 Citations/yr = 4,212 Citations by anesthesia Citations to anesthesia My final perspective from this retrospective look at car­ journals = 51.5% journals = 37.6% diovascular anesthesia is that, its evolution primarily was a responsive one and not an innovative one. This is prob­ Anesthesia journals: Anesthesiology; British Journal of Anesthesia; Critical Cure Medicine; Acta Anaesthesiologica Scandinavica; Anaesthesia Intensive ably true of anesthesiology as a specialty. We respond to Care; Canadian Anaesthetists Society Journal; Anaesthesia; Anaesthesist; new surgical therapies by finding better ways of coping Anesthesia and Analgesia. with new surgical problems. We never find the best way because we never measure outcome..But we are clearly any case, the data that I obtained from his organization responsive. consisted of lists showing the frequency that various jour­ Considering all the time anesthesiologists spent over nals cited articles published in our Journal and the fre­ these years with the sickest cardiovascular patients, I asked quency that various journals were cited in the articles what did we as anesthesiologists contribute directly to published by our Journal. I will show you what I found. the body of knowledge of cardiovascular disease, to un­ First let me give you a sobering statistic. About 25% derstanding its mechanisms and treatment? I exclude from of all scientific papers published are never cited by anyone the answer whatever anesthesiologists may have contrib­ at any time. Unfortunately, like Vandam's paper on the uted to basic science in physiology or pharmacology, con­ environment, I have written quite a few of these myself. tributions that eventually may translate to clinical care. So much for rewards for the sweat and tears that go into But what did we contribute directly to clinical cardiology writing a paper. or to cardiovascular surgery? Relying on my memory The first question I asked is how much we as anes­ alone, I found some contributions, but not very much. thesiologists write for each other compared with writing My impression was that we incorporated a great deal of for physicians outside our specialty. I elected to use the cardiology and cardiac surgical physiology into our own most recent data because they are more complete. They body of knowledge. cover a 5-year period, from 1978-1982 (table 4). Note I wondered next if responsiveness rather than inno­ that 527c of all citations to our Journal are by other vation was true of all special areas of anesthesiology or anesthesia journals and 38% of the references in our unique to my experience. I used the only method I know Journal are to other anesthesia journals. I considered the to get some feeling for this, through the use of citation nine journals in Table 4 as encompassing the world's analysis. major anesthesia literature. Citation analysis is a technique of library science pop­ Obviously, we do a great deal of talking to each other. ularized during the past 20 years by Eugene Garfield and I don't know whether we are better or worse than other his Institute for Scientific Information in Philadelphia. specialties in this regard. 1 did not compare it with another He is the one who publishes Current Contents. Garfield specialty group, because there are special hazards in com­ puts in his computer the titles and authors of all articles paring journals between specialities. published in all important scientific journals. He also puts Thus, only 48% of all the citations to articles in our in the authors and titles of all papers cited in the references Journal are by nonanesthesia journals. I then looked in of each of these articles. He then can do some extraor­ more detail at who cited us and whom we cited by dividing dinary analyses based on titles, journals, and authors. In our specialty in subspecialty areas (table 5). In each of

TABLE 5. Nonanesthesia Journals that Most Frequently Cite ANESTHESIOLOGY and Are Cited by ANESTHESIOLOGY

Specialty Nonu n„,h«iajol mills

Veterinary Journal of the American Veterinary Medical + American Journal of Veterinary Research Association Neurosurgery Journal of Xeurosurgery + Stroke Pulmonary medicine Chest + American Rei>ieu< of Respiratory Disease Pediatrics Journal of Pediatrics + Pediatrics Obstetrics and gynecology American Journal of Obstetrics and + Obstetrics and Gynecology Gynecology Cardiovascular surgery Journal of Thoracic and Cardiovascular + Circulation Surgery Cardiology American Journal of Cardiology + American Heart Journal General medicine Journal of the American Medical Association + Neiv England Journal of Medicine Anesthesiology 474 ARTHUR S. KEATS V 60, No 5, May 1984

TABLE 6. Ratios by Specialty Area of Frequency with which Apart from confirming this perspective that cardio­ Nonanesthesia Journals Cite ANESTHESIOLOGY to Frequency vascular anesthesia was primarily responsive rather than They Are Cited by ANESTHESIOLOGY (1978-1982) innovative, I believe there are other implications in these Citations per Year by and lo numbers. It is obvious we now do a lot of talking to each Nonanesthesia Journals other. Much of that is inevitable with technical matters

Whom l)o and equipment and drugs unique to our specialty. But if Who Cites Us? We Cite? we are considering subspecialty certification, we inevitably Ratio (2.629/yr) (2.678/yr) will engender subspecialty journals with the further in­ Veterinary 58.6 12.2:1 4.8 evitable result that we will talk even more to each other Neurosurgery 56.8 1.8:1 31.8 and less and less to medicine at large. If we increase our Pulmonary medicine 55.6 1.3:1 42.0 specialty journals, we will further isolate ourselves from Pediatrics 23.2 1:1 24.2 . Obstetrics and gynecology 30.6 1:1.8 55.2 general medicine progressing to an enclave within med­ Cardiovascular surgery 36.2 1:2.2 79.2 icine. I believe journal proliferation would bean unhappy 1.2.7 44.8 Cardiology 16.6 development in our specialty. I believe, as did the late General Medicine 38.8 1:3.5 134 Myron Laver, that anesthesiology is at its best when the observations it makes on the sample of patients we care for apply equally to all patients and contribute benefits these areas, there were two clinical journals that had a to medicine at large. He was one of our finest examples high frequency of interaction with our Journal, that is, in this regard. they cite us or we cite them. I then calculated the annual A second implication is that we as a Society have been frequency with which they cited us and we them, over anxious to let the public know who we are and spent the 5-year period, deriving ratios that might answer the much time and money to accomplish this. But much of question I posed (table 6). The method seems to have our professional satisfaction and happiness comes from some validity, since we have at one end, veterinary med­ our interaction with and respect from our professional icine journals, which draw heavily from our Journal and colleagues. For our own professional gratification, we we draw almost nothing from theirs. At the other end, need to let other physicians know who we are. We can we draw heavily from general medical journals, as all do this by publishing in their journals. specialties do, and this is as expected. My performance has come to an end. I presented you But look at the values in between. I believe it confirms with some perceptions and perspectives gleaned from my my observation that cardiovascular anesthesia drew participation in the evolution of cardiovascular anesthesia. heavily from cardiology and cardiovascular surgery in You now will conclude how broadly they relate to other increasing its body of knowledge rather than contributing areas of our specialty. Like all free theme discourses, this to it. Conversely, it might be concluded that at least during one should have a message. And it does. The message is the past 5 years we contributed more to clinical neuro­ that I hope you enjoyed listening as much as I appreciated surgery and pulmonary medicine than we took from it. your generous attention. -7- NEUROANESTHESIA AND THE ACHIEVEMENT OF PROFESSIONAL RESPECT by John D. Michenfelder, M.D.

Anesthesiology 70:695-701, 1989 SPECIAL ARTICLE

The 27th Rovenstine Lecture: Neuroanesthesia and the Achievement of Professional Respect

John D. Michenl'elder, M.D. *

I AM HONORED and privileged to be chosen to present I chose it because of its brevity and because I have a pro­ this, the 27th Rovenstine Lecture. I am of that generation found, and admittedly peculiar, distaste for articles enti­ who did not know Dr. Rovenstine personally. However, tled "Anesthesia for, etc.. . ."Six weeks later, I had the having heard most of my predecessors at this podium, reviewers comments. Comment #1 from the first reviewer many of whom did know him, I feel as if I also knew was "I prefer 'Anesthesia for Neurosurgery.' " A few him—at least in spirit. Were he present today, I believe weeks later, I returned the revision to Dr. Vandam with he would be proud, for the most part, of the specialty a covering letter that included the following "I still prefer which he so influenced in uncounted ways during its early 'Neuroanesthesia.' " Shortly thereafter, I received a letter formative years. I'm sure too that he would have been of acceptance from Dr. Vandam in which he stated "I 1 disappointed in some of our failings. His influence ob­ shall abide by the decisions you have made." The article viously continues on by way of the many anesthesiologists was surprisingly well received and, so it seems, thanks to whom he trained and who have been, for a number of my naive persistence and to Dr. Vandam's kindly wisdom, us, role models in academic anesthesiology. Dr. Roven­ we became known as neuroanesthetists rather than what, stine was among the first of the truly academic anesthe­ I wonder: "anesthetists for neurosurgery," perhaps? siologists, and it is this heritage that he and others passed I would like to consider some of the scientific achieve­ on which we must continue to nurture and allow to grow. ments made by neuroanesthetists. I shall focus on what I We cannot forget, of course, that anesthesiology as a consider to be three major contributions we have made medical specialty is responsible for clinical service, but we to the care of neurosurgical and/or critical care patients. must never allow the clinical pressures for delivering ser­ I was fortunate to have been personally involved to some vice to choke off academic pursuits. In too many depart­ extent in all three. While I shall sing our praises, I fear ments across the country, this has been allowed to occur. that, in each instance, our achievements have been dis­ To the degree that we permit it to occur, we shall never torted, abused, and misinterpreted by some of our own fully gain the professional respect we seek from our col­ colleagues, including anesthesiologists, neurosurgeons, leagues in the other medical specialties. and neurologists, whom, for lack of a better term, I shall I intend in this presentation to consider aspects of the label as psuedoacademicians. process and some of the pitfalls in the achievement of Let me begin with the effect of anesthetic agents and professional respect using examples taken from my chosen techniques on cerebral blood flow, cerebral metabolism, subspecialty: neuroanesthesia. As an aside, you might be and intracranial pressure. When, in 1961, I told Dr. Al­ interested in knowing how I believe this subspecialty came bert Faulconer, the first chairman I served under at the to be so named. In 1968, I submitted an invited review Mayo Clinic, that I wanted to work exclusively with the article authored by myself and Drs. Gerald Gronert and neurosurgeons, he was incredulous; I know he suspected Kai Rehder to the then Editor-in-Chief of ANESTHE­ my sanity, but it was an offer he could not refuse. At that SIOLOGY, Dr. Leroy Vandam, with a covering letter that time, cardiac surgery and cardiac anesthesia were the gla­ included the following: "Regarding the title 'Neuro­ morous subspecialties in the operating rooms, having only anesthesia,' I recognize it is not a generally accepted term. recently conquered most of the major problems of car­ diopulmonary bypass. Physicians practicing these subspe­ cialties seemed to know what they were doing and why * Professor of Anesthesiology, Mayo Medical School; Consultant in they were doing it. But, in neurosurgery, it was like a Anesthesiology. Accepted for publication from the Department of Anesthesiology, different era. Even then, open drop ether induction in Mayo Clinic, Rochester, Minnesota 55905. Accepted for publication children was commonplace. I can remember watching pe­ December 8, 1988. Presented on October 10, 1988, at the Annual diatric patients with brain tumors fighting violently as they Meeting of the American Society of Anesthesiologists in San Francisco. were taken through the slow laborious stage II of ether Address reprint requests to Dr. Michenfelder. anesthesia. I wondered what must be going on in their Key words: Anesthesia: neurosurgical. Brain: blood flow; protection. Embolism: air. History: neuroanesthesia. heads as this process evolved finally into the quiet of stage

695 Anesthesiology 696 JOHN D. MICHENFELDER V 70, No 4, Apr 1989 III anesthesia. The literature was largely barren of any one of the most fascinating lectures I have ever heard information. There were a few exceptions: by 1960, Dr. was that given by the renowned physiologist, Dr. Her­ Harvey Slocum had introduced the use of controlled hy­ mann Rahn, concerning his work in poikilotherms which perventilation for brain tumor patients in his military provided the basic evidence against temperature correc­ 5 practice at Walter Reed Hospital arguing that it resulted tion for PaCox and pB. values. Interestingly, that lecture in a more relaxed brain.2 At the Mayo Clinic, Drs. Edward happened to be the 7th Rovenstine lecture given in 1968, Daw and Howard Terry were in the process of attempting 1 year before the Glasgow work was published. In any to introduce controlled hyperventilation, while several of case, the anonymous editorial in the British Journal of An­ our neurosurgeons remained opposed. In truth, none of aesthesia utterly condemned the use of any of these volatile us really knew what we were doing or why; we were lit­ anesthetics in.neurosurgical patients at risk and concluded erally groping in the darkness. that even hyperventilation is without effect. I recently This changed within a few years when the group at the discussed this work with two of Dr. McDowall's early co­ University of Pennsylvania, including Drs. Harry Woll- workers, Drs. William Fitch and John Barker. They man, Craighead Alexander, and Peter Cohen, began to pointed out that in none of their publications did they report their findings regarding the effects of anesthetics ever arrive at a clinical recommendation that anesthetics on cerebral blood flow and cerebral metabolism in vol­ such as halothane were absolutely contraindicated in these unteers; while the group in Glasgow, including Drs. Gor­ patients. Rather, it was those who had not done the work don McDowall and Murray Harper, began to report their that arrived at these conclusions. findings regarding the effects of anesthetics on cerebral But the die was cast. Never mind that halothane had blood flow and metabolism in experimental animals. been the most commonly used anesthetic in neurosurgery Stimulated by these early reports, I was soon encouraged for almost 10 years the world around at that time. Never and accommodated by Dr. Richard Theye in 1964 to mind that up to that time no neurosurgeon had made pursue similar studies in his laboratory. I jumped at the known his suspicions that halothane caused a tight brain. opportunity and have been involved in such activities ever Never mind that at the Mayo Clinic alone we had anes­ since, with the generous support of both the Mayo Clinic thetized more than 2000 patients undergoing craniotomy and the National Institutes of Health. By 1969, most of using halothane, and neither anesthetist nor surgeon ever the basic knowledge regarding the effects of anesthetic recognized an intracranial pressure problem. Certainly agents on cerebral blood flow, cerebral metabolism, and the latter group, i.e., the neurosurgeons, are not noted intracranial pressure was in the literature, and much of for their reluctance to identify such problems. it came from the three laboratories I have mentioned. In response to this sudden condemnation of volatile This, then, was a major achievement and was accom­ anesthetics, we and others did studies to further elucidate plished almost exclusively by academic anesthesiologists. the effects of halothane. In our study, as reported by We had moved from a state of profound ignorance to Adams et al.,6 we clearly demonstrated that by the simple one of sophisticated understanding. We could discuss in expedient of prior hyperventilation (i.e., producing true depth what each of our drugs or interventions and their hypocarbia at nor mother mia), clinically significant in­ combinations might do to cerebral blood flow, cerebral creases in intracranial pressure do not occur upon intro­ metabolism, and intracranial pressure. ducing 1% halothane in patients at risk. Almost reluc­ And then, in my opinion * something went wrong. It tantly, it seemed, most agreed that, yes, you can use halo­ began in 1969, when a report in Lancet5 summarized the thane, but you should avoid it if you can. To this day, I Glasgow group's findings regarding the effects of certain do not know why I should avoid it* We also showed in volatile anesthetics on intracranial pressure in patients that study why the potential effects of halothane on in­ with brain tumors. It was followed by an anonymous ed­ tracranial pressure had never previously been appreciated. itorial in the British Journal of Anaesthesia.* The report in In those patients studied without prior hyperventilation, Lancet demonstrated that with halothane, trichlorethy- about one-third did experience some increase in intra­ lene, and methoxyflurane, intracranial pressure increased cranial pressure following simultaneous introduction of immediately upon introduction of the agent. Further­ halothane and hyperventilation. But even in these, the more, it was stated that this increase in ICP was not pre­ increase lasted less than 30 minutes followed by sponta­ vented by "hypocarbia." However, this was not true hy- neous return usually to below baseline. Thus, by the time pocarbia—the patients were intended to be studied at the craniotomy was completed, any effect of halothane normocarbia but, because of inadvertent temperature on intracranial pressure or brain mass was dissipated. decreases, the corrected PaCo2 resulted in values below But the pattern had been established and remains to 35 mmHg. If you believe, as I do, that physiologically this day. In short, any intervention or drug which can be such correction is wrong, then, in fact, none of their pa­ shown to cause any increase in ICP provides a license for tients were truly hypocarbic. As an aside, I might add that condemnation, at least by the psuedoacademicians. Never Aneitheiiology V 70, No 4. Apr 1989 NEUROANESTHESIA 697 mind that the reported increase in intracranial pressure creases in intracranial pressure in patients with brain tu­ may only be of the magnitude of 10 or 15 mmHg (or mors. But to recommend instead that an unreliable hy­ less). A favorite gambit by these pundits is to report in­ potensive agent such as trimethaphan should be used be­ creases in intracranial pressure as a percentage of control cause it's perhaps less likely to induce a modest increase to perhaps as much as 200-400% or even more I Shocking 1 in intracranial pressure is clinical nonsense. In patients Until one notes that the increase is from 5 mmHg to per­ with aneurysms, for example, immediate reliable control haps 10 or 20 mmHg. Why should such increases concern of systemic blood pressure is essential. Do not replace us? Daily, we allow mean arterial pressure to decrease or nitroprusside with trimethaphan for such patients. To do increase by this magnitude without any concern. So surely so is accepting ill-directed advice. it is not the effect on cerebral perfusion pressure that Why the eagerness to condemn? Is it some form of causes us to worry about such ICP increases. Are we con­ demagoguery? Does it imbue the condemner with some cerned about herniation of brain tissue through fixed sense of power? I am struck that more often than not the structures? Yes, of course. But, again, not with only mod­ ones who condemn are not the ones who did the work; est increases in intracranial pressure. Indeed, I challenge more commonly, it is the hangers-on, the psuedoacade- any of you to find a single case report of an anesthetic- mician. In my opinion, concern about intracranial pres­ induced intracranial disaster, such as herniation, since the sure has become a fetish among self-appointed so-called early days of ketamine when it was incorrectly used for "expert" neuroanesthetists. They have promoted the un­ neurodiagnostic procedures, or since the days when ni­ important to the status of importance, possibly as a means trous oxide was used incorrectly during air contrast stud­ of gaining self-importance. Those who promote such fe­ ies. Granted, halothane and the other volatile anesthetics tishes for whatever reason should be challenged to provide have the potential to induce such a disaster, but, if used logical support for their position backed up by hard sci­ correctly, they will not do so. entific data. Without such, their opinions should not be The list of currently popular agents condemned by our respected and they should be ignored. Neither is this psuedoacademic associates is mind-boggling: halothane, problem unique to neuroanesthesia. I would only point enflurane, isoflurane, nitrous oxide, ketamine, d-tubo- to the recent furor regarding isoflurane's potential for curarine, atracurium, pancuronium, succinylcholine, ni­ producing coronary steal as another example of probable troglycerin, and nitroprusside are ones that come im­ premature condemnation with only marginal scientific mediately to mind; I'm sure there are others. All share foundation. in common that, under the proper circumstances, it is A second scientific area wherein our specialty might possible to induce some increase in intracranial pressure take pride is that work dealing with the potential for pro­ with these drugs. Take d-tubocurarine. One study from tecting and/or resuscitating the brain. Since the mid Finland7 showed that, when you give a large bolus dose 1950s, anesthesiologists, along with neurosurgeons, car­ of 0.6 mg/kg to spontaneously breathing patients, you diac surgeons, physiologists, and neuroscientists, have will produce a modest transient increase in intracranial made major contributions to our understanding of the pressure from 10 to 18 mmHg for a short period of time neuroprotective effects of hypothermia. That this is now of less than 2 minutes, possibly due to histamine release. an established and reasonably well understood protective Therefore, condemn it? Nonsense I The increase itself was intervention is certainly in part due to the many valuable probably unimportant, and if you want to avoid that, sim­ contributions made by a number of academic anesthe­ ply don't give large bolus doses. Take isoflurane. In two siologists. 8,9 human studies, including one from my institution, it With the explosion of information in the mid to late was concluded that isoflurane plus hyperventilation was 1960's regarding the effects of anesthetics on cerebral safe in patients with intracranial mass lesions. But, in a 10 blood flowan d metabolism, it was natural to explore the third study, the authors concluded differently, even potential for possible neuroprotective effects of some of though eight of 14 of their patients had no increase in these anesthetics and other drugs. Throughout the 1970s, intracranial pressure, while, in their remaining six pa­ attention was focused largely on the potential of barbi­ tients, the increase in intracranial pressure was so modest turates for brain protection or resuscitation. Much of this that there was no need to change the protocol or to dis­ work came from anesthesiology laboratories, but by no continue the isoflurane. What, then, was the basis for their means all of it; neurologists, neurosurgeons, and basic conclusion that "Isoflurane may not be a benign anesthetic neuroscientists have also been deeply involved in this field. in patients known to be at risk for increases in intracranial Among the anesthesiology laboratories that have made pressure"? To extrapolate clinically insignificant mea­ major contributions, I would include Dr. Peter Safar's, surements of increased intracranial pressure to potential Dr. Harvey Shapiro's, and, perhaps immodestly, my own. intracranial disasters is without foundation and should be Throughout the 1970s, the topic was controversial and ignored. Take nitroprusside. Yes, it can cause modest in­ often heated. This controversy was, of itself, good in that Anesthesiology 698 JOHN D. MICHENFELDER V 70, No 4, Apr 1989 it stimulated considerable interest and a great deal of plete cerebral ischemia and despite the fact that the drug work. As a result, we have today a fairly good grasp of is virtually innocuous in humans as regards systemic or the circumstances during which barbiturates might pro­ other CNS effects, it has been argued by some of our tect the brain—namely, during incomplete ischemia or peers in this country that more animal studies are needed partial hypoxia. We also know that barbiturates will nei­ before we dare give it to patients. Fortunately, the Eu­ ther protect the brain during complete ischemia nor offer ropeans have not seen it this way, and the appropriate any potential for resuscitating the brain following com­ studies are ongoing in patients. Similarly, the demonstra­ plete ischemia (i.e., cardiac arrest).11 We also know that, tion in patients by Nussmeier et al.20 that high-dose bar­ although barbiturates have the capacity to decrease in­ biturates during cardiopulmonary bypass reduces neu- tracranial pressure, they do not improve prognosis in ropsychiatric complications, although not challenged, has head-injury patients. For the most part, we have a rea­ not apparently had any major impact as yet on anesthetic sonable understanding of at least some of the mechanisms practices. Granted, high-dose barbiturate therapy during that account for these barbiturate effects. cardiopulmonary bypass is not an innocuous intervention The methodologies learned in dissecting out the bar­ for the reasons already considered and perhaps practice biturate story during the 1970s are now being applied to should not change, but I suspect the original embarrassing a host of other pharmacologic interventions that might experience with barbiturates following cardiac arrest has provide brain protection or resuscitation. These include raised a red flag of caution of such proportion that all are isoflurane, calcium entry blockers, free-radical scavengers, hesitant to walk that path again. Yes, we may be proud iron chelators, and excitatory amino acid antagonists. One as a specialty of our contributions, but not our applications of these, the calcium entry blocker nimodipine, has al­ in so far as brain protection and resuscitation are con­ ready been shown in primates in my laboratory to impact cerned. favorably on brain resuscitation following complete global A third area to which neuroanesthesiologists have made ischemia as reported by Steen et a/.12 In humans, nimo­ major and almost exclusive contributions is that of diag­ dipine has been reported to improve outcome in cardiac nosing and managing venous air embolism. When I first arrest patients when compared to a retrospective historical began practice as a consultant in 1961, the complication group13 and the drug is now undergoing trial in a ran­ of venous air embolism in patients operated while in the domized prospective study in Europe. In addition, ni­ sitting position for posterior fossa surgery was considered modipine has been shown in humans to improve outcome to be rare—probably less than 1%. At the same time, it in acute ischemic stroke14 and to decrease the mor­ was recognized that, when the complication did occur, 21 bidity secondary to cerebral vasospasm in aneurysm the mortality was high—usually over 50%. Diagnosis of patients.15-17 The potential for an exciting breakthrough air embolism was dependent on recognizing the so-called in this fieldi s a real one, and our specialty will have played "mill wheel" murmur with either a precordial or esoph­ a major role in this development should it come about. ageal stethoscope. We now know that the "mill wheel" So there is reason to be proud. But have we forgotten murmur is a late sign indicative of a large volume of in­ the uncounted thousands of patients who were subjected tracardiac air and is audible only if the heart is still able to prolonged barbiturate-induced coma during the mid to contract with some vigor. to late 1970s and into the early 1980s? Anesthesiology All of this began to change as the result of two repetitive must take the blame for that as well, and, as such, we must serendipitous events that occurred at the Mayo Clinic in lose some of the respect that was so arduously gained. the early to mid 1960s. For reasons I've long since for­ How many patients were hurt by such an intervention? gotten, I was interested in measuring central venous pres­ No one knows, but certainly none were helped. How did sure in patients operated on while in the sitting position. this come about? Largely as the result of a single positive Catheters were inserted somewhere in the superior vena primate study,18 which later proved to be irreproducible,19 cava for this purpose without precise localization. On one an enthusiastic group of proponents, and a plethora of occasion, a patient being so monitored developed signs physicians who were grasping for anything, simply any­ that were at least suspicious of air embolism: hypotension, thing, that might help. It would have been different, per­ premature ventricular contractions, and a low grade sys­ haps, if barbiturates, like steroids, were associated with tolic murmur on the esophageal stethoscope. An associate, little down-side risk, but the hemodynamic and CNS ef­ I believe Dr. Edward Daw, suggested that I aspirate the fects of a high dose of barbiturates alone represent major catheter. Upon doing so, we were amazed that over 100 interventions that should not be introduced lightly. It is ml of air were aspirated over the next several minutes to be hoped that we have learned from this rather sorry and all of the patient's signs of air embolism disappeared. experience—perhaps we have overlearned. We thought this a unique experience that likely would Thus, despite the unchallenged demonstration in pri­ never be repeated. We did not change our practice, we mates that nimodipine improves outcome following com­ did not report the case. But within a few months in an- Anesthesiology V 70, No 4, Apr 1989 NEUROANESTHESIA 699 other patient being monitored with a catheter in the su­ ception of air embolism in patients operated in the sitting perior vena cava, the experience repeated itself almost position from that of a rare complication with a high mor­ exactly. Now we did change our practice and began to tality rate to that of a common complication with a min­ insert catheters in all patients being operated in the sitting imal mortality rate. The key, of course, has been early position. The first problem was where to localize the tip recognition by highly sensitive accurate monitors. We, as of the catheter. Pulmonary artery catheters were not a specialty, can and should be proud of this story. available at that time, so this was not even a consideration. But, once again, I believe we have tripped over our Ironically, at this very same time, Dr. Jeremy Swan of own successes and thereby have diminished the respect eventual Swan—Ganz catheter fame was walking the halls otherwise gained. There are those who contend it is mal­ just one floor above us working in his cardiac catheter­ practice and negligent to operate on a patient in the sitting ization laboratory. We attempted placement of the cath­ position without a central venous catheter. In my practice, eter in the right ventricle, but this resulted in a high in­ we have done so on occasion for all these years and con­ cidence of premature ventricular contractions and diffi­ tinue to do so. Granted, we always try to insert such a culty in aspirating the catheter. Thus, by elimination, we catheter and we usually succeed. But if a reasonable effort selected the right atrium, assuming it would be more ef­ is without success, we will proceed after appropriate con­ fective than superior vena caval placement. Thereafter, sultation with the attending neurosurgeon and an appro­ we began to catalogue the early signs of air embolism priate note in the chart. Rarely, if ever, would we cancel consisting primarily of a characteristic low grade systolic such a case. I believe it analogous to the circumstance of murmur detectable by the esophageal stethoscope and failing to insert a pulmonary artery catheter in a situation confirmed by aspiration of air bubbles. where one is indicated. Most would not cancel such a case, In 1969, we reported the "true" incidence of air em­ but would proceed with, perhaps, a degree more anxiety, bolism, proven by aspiration of air bubbles, to be about but certainly not negligently. 7% with no morbidity or mortality.21 From this modest There is another group of our peers that contends that beginning, our knowledge of venous air embolism grew central venous catheters for air embolism should be in­ exponentially. Probably the most important contribution serted in all patients undergoing craniotomy, regardless during this time was the introduction of the Doppler in of position. True, there is a measurable incidence of air 1969 by a neurosurgeon, Dr. Joseph Maroon, and an En­ embolism during craniotomy in the horizontal position glish anesthetist, Dr. John Edmonds-Seal.22 They reported but, unless the body is to be placed in a distinct head-up a remarkably high incidence of air embolism of over 50% position, the risk of a major embolic event is virtually nil in a small group of only seven patients operated on while and no catheters are required. The logic of those who in the sitting position for posterior fossa pathology. In argue the opposite could be extended, such that all pa­ disbelief, we adapted a Doppler designed for fetal mon­ tients undergoing surgery of any kind in the horizontal itoring and, much to our surprise, confirmed the Maroon position should have a central line inserted for air em­ report by aspirating air bubbles in over 40% of our pa­ bolism. I reject such arguments as being in the same cat­ tients when the Doppler developed characteristic sounds egory as those concerned with unimportant increases in of air.23 intracranial pressure—a fetish without scientific foun­ Since that breakthrough, most of the progress repre­ dation. sents finetunin g of our understanding of the complication Finally, many of our peers have taken what I consider and of our monitoring techniques. Mortality from venous to be our triumphant experience in conquering most of air embolism in neurosurgery is now almost unheard of. the problems of the sitting position and have converted Morbidity is likewise negligible. The one exception is that it to an argument for condemning the sitting position. rare complication of a symptomatic episode of paradoxical They again use words such as malpractice and negligence. air embolism, i.e., air crossing to the systemic arterial cir­ But where is the evidence for harm due to the use of the culation resulting in either stroke or coronary emboliza­ sitting position? Two recent retrospective studies revealed tion. Even that complication can now be diagnosed intra- that there are minimum complications,27,28 while, in a operatively using a transesophageal echocardiograph, as third study from the Mayo Clinic, Black et al.29 did a ret­ was reported by Cucchiara et al.2b We also now know, rospective comparison over the same time period of pa­ thanks to the work of Bunegin et al.26 that placement of tients operated in the horizontal versus the sitting position the catheter tip is probably best just above the junction for posterior fossa pathology and reported no important of the superior vena cava with the right atrium and that differences, while those few differences that did exist air retrieval is further improved by the use of catheters tended to favor the sitting position. with multiple orifices. Choice of patient position is a surgical decision. As the This, then, is a story of steady remarkable progress responsible anesthesiologist, we may disagree with the whereby academic anesthesiology has converted our per­ surgeon and, if we do, we should express that opinion. If Alien lirunlojp 700 JOHN D. MICHENFELDER V70. No 4, Apr 1989

a lot, and for the better, since 1958, but we will never have the glamour and the automatic aura of respect that is conferred upon the brain surgeon, the heart surgeon, or the transplant surgeon. Neither have we yet gained the automatic respect conferred upon internists for their perceived pursuit of the intellectual aspects of medicine. We are, instead, like that financial institution which ad­ vertises on T.V.—Smith Barney—as regards respect; we must gain it the old fashioned way—we must earn it. And, in my opinion, that's fair enough. We gain the respect of our medical peers and of our patients by demonstrating our professional skills, our knowledge, and our reliability on a day-to-day basis while working in the trenches. As we are required to earn the respect of our associates, so, too, may we lose any opportunity to gain that respect. Certainly it is true in the academic world that an individual who attempts to promote his or her career by taking short cuts, by plagiarizing the work of others, by fragmenting a set of data into multiple reports, or perhaps even by creating false data is quickly recognized by his or her peers and is shunned. That person is correctly labelled a liar, a cheat, and a coward, for he or she was without the courage FiG. 1. The Cure of Folly by Hieronymus Bosch, 1450-1516. or fortitude to do what must be done to achieve profes­ sional respect legitimately. the surgeon insists, we have the choice to either agree or In addition to earning respect in the trenches of the to withdraw from the case. We do not have the obligation operating room, the delivery suite, the pain clinic, the to "educate" the neurosurgeon regarding the dangers of emergency room, or the intensive care unit, we must con­ the sitting position. Rather, if we accept the case, we have tinue to strive for respect in the academics of our specialty. the obligation to render the use of that position as safe I have highlighted but three areas of my chosen subspe­ as possible for the patient. The evidence is clear that we cialty of neuroanesthesia wherein academic anesthesia have the means to do so. We need not continually prove played a major role in advancing our knowledge and how prescient that remarkable 15th century painter, hence improving patient care. There are, of course, many Bosch, was when he painted "The Cure of Folly" depict­ other such examples in my own and the other subspe­ ing intracranial surgery performed on a sitting subject cialties. I have said that, despite occasional abuses, we can (fig. 1). Bosch was big on symbols: according to art his­ and should take pride as a specialty in these achievements, torians, the funnel identifies a deceitful person or false for it is these types of achievement that gain the respect doctor, while the closed book symbolizes the futility of of our colleagues. However, we must not simply rest on knowledge in dealing with human stupidity. So much for our laurels. It is my opinion that most of the progress Bosch and the sitting position. that has been made has been the result of phenomeno- logical research. That is, we have explored successfully In my opening remarks, I made reference to the im­ the "whats" of the problems and not the "whys." There portance of earning the respect of our medical colleagues. is nothing wrong with this. Indeed, it is necessary to first I sometimes think that God had intended Rodney Dan- recognize and describe the phenomenon before one can gerfield to be an anesthesiologist rather than a stand-up explore its causes. I am not ashamed to admit that 1 am comic. His repetitive lament that "I don't get no respect" largely a phenomenologist as regards the nature of my is one that I have heard from anesthesiologists since I research, and so too are most of my peers. But now we began my residency in 1958. It is true that, when you need the next generation, the next step. We need indi­ embark on a career in anesthesiology, you do not auto­ viduals with backgrounds in basic science who can explore matically gain the respect of your medical peers, your the mechanisms behind the phenomena. Once mecha­ patients, the lay press, or even of your own family. I re­ nisms can be clarified, then interventions can be designed member with clarity my mother in 1958 saying, upon to alter the phenomena in a way favorable to the patients announcing my intentions, "Anesthesia? But I thought we care for. The future of academic anesthesiology is only nurses did that;" and my medical advisor in the navy, bright, but it must now incorporate the basic scientist as a crusty old four-striper, saying "But lieutenant, you're well as the clinically oriented academic anesthesiologist. good enough to be a real doctor." Things have changed Anetthetiology V 70, No 4, Apr 1989 NEUROANESTHESIA 701

We must replace the psuedoacademicians with true aca­ 12. Steen PA, Gisvold SE, Milde JH, Newberg LA, Scheithauer BW, demicians. Lanier WL, Michenfelder JD: Nimodipine improves outcome when given after complete cerebral ischemia in primates. In closing, I would like to paraphrase one of my heroes: ANESTHESIOLOGY 62:406-414,1985 Sir Winston Churchill. When he was confronted in his 13. Roine RO, Kaste M, Kinnunen A, Nikki P: Safety and efficacy of waning years with a critic who charged, based upon his nimodipine in resuscitation of patients outside hospital. Br Med highly celebrated habits of beginning the day with a large J 294:20, 1987 cigar and cognac and continuing in that vein until the 14. Gelmers HJ, Gaorter K, deWeerdt CJ, Wiezer HJA: A controlled trial of nimodipine in acute ischemic stroke. N Engl J Med 318: early hours of the next morning, that probably he, Sir 203-207, 1988 Winston, had not drawn an entirely sober breath since 15. Allen GS, Ahn HS, Preziosi TJ, Battye R, Boone SC, Chou SN, his youth, the great man supposedly responded: "Yes, Kelly DL, Weir BK, Crabbe RA, Lavik PJ, Rosenbloom SB, that's probably true, but I believe I've gotten much more Dorsey FC, Ingram CR, Mellits DE, Bertsch LA, Boisvert DPJ, out of alcohol than alcohol ever got out of me." Hundley MB, Johnson RK, Strom JA, Transou CR: Cerebral arterial spasm—Controlled trial of nimodipine in patients with Now, regardless of how one may view such use, or pos­ subarachnoid hemorrhage. N Engl J Med 308:619-624, 1983 sibly even addictive abuse, of alcohol, the typical pithy 16. Philippon J, Grob R, Dagreou F, Guggiari M, Rivierez M, Viars symmetry of that Churchillian phraseology struck a chord P: Prevention of vasospasm in subarachnoid hemorrhage. A with me as I contemplated how to bring this to an end. controlled study with nimodipine. Acta Neurochir 82:110-114, Presumably, I was asked to give this, the 27th Rovenstine 1986 17. Petruk KC, West M, Mohr G, Weir BKA, Benoit BG, Gentili F, lecture, because in the opinion of at least some, I have Disney LB, Khan MI, Grace M, Holness RO, Karwon MS, Ford made a few contributions to the specialty during the past RM, Gameron GS, Tucker WS, Purves GB, Miller JDR, Hunter 30 years. I sincerely hope so. But, regardless of how you KM, Richard MT, Durity FA, Chan R, Clein LJ, Baroun FB, may perceive any such contributions, I can say this to you Godon A: Nimodipine treatment in poor grade aneurysm pa­ and with genuine humility, gratitude, and even apology: tients. Results of a multicenter double blind placebo controlled trial. J Neurosurg 68:505-517, 1988 although I may be addicted to this specialty, and as such 18. Bleyaert AL, Nemoto EM, Safar P, Stezoski W, Mickell JJ, Moossy have invested an enormous amount of time and effort in J, Rao GR: Thiopental amelioration of brain damage after global it, I have gotten much more out of anesthesiology than ischemia in monkeys. ANESTHESIOLOGY 49:390-398, 1978 anesthesiology ever got out of me. 19. Gisvold SE, Safar P, Hendrickx HHL, Rao G, Moossy J, Alexander Thank you. H: Thiopental treatment after global brain ischemia in pigtailed monkeys. ANESTHESIOLOGY 60:88-96, 1984 20. Nussmeier NA, Arlund C, Slogoff S: Neuropsychiatry compli­ References cations after cardiopulmonary bypass: Cerebral protection by 1. Michenfelder JD, Gronert GA, Rehder K: Neuroanesthesia. a barbiturate. ANESTHESIOLOGY 64:165-170, 1986 ANESTHESIOLOGY 30:65-100,1969 21. Ericsson JA, Gottlieb JD, Sweet RB: Closed-chest cardiac massage 2. Slocum HC, Hayes GW, Laezman BL: Ventilator techniques of in the treatment of venous air embolism. N Engl J Med 270: anesthesia for neurosurgery. ANESTHESIOLOGY 22:143-145, 1353-1356, 1964 1961 22. Michenfelder JD, Martin JT, Altenburg BM, Rehder K: Air em­ 3. Jennett WB, Barker J, Fitch W, McDowall DG: Effect of anesthesia bolism during neurosurgery. An evaluation of right-atrial cath­ on intracranial pressure in patients with space occupying lesions. eters for diagnosis and treatment. JAMA 208:1353-1358, 1969 Lancet 1:61-64, 1969 23. Maroon JC, Edmonds-Seal J, Campbell RL: An ultrasonic method 4. Anonymous: Halothane and neurosurgery (editorial). Br J Anaesth for detecting air embolism. J Neurosurg 31:196-201, 1969 41:277, 1969 24. Michenfelder JD, Miller RH, Gronert GA: Evaluation of an ul­ 5. Rahn H, Reeves RB, Howell BJ: Hydrogen ion regulation, tem­ trasonic device (Doppler) for the diagnosis of venous air em­ perature, and evolution. Am Rev Respir Dis 112:165-172,1975 bolism. ANESTHESIOLOGY 36:164-167,1972 6. Adams RW, Gronert GA, Sundt TM Jr, Michenfelder JD: Halo­ 25. Cucchiara RF, Nugent M, Seward JB, Messick JM: Air embolism thane, hypocapnia and cerebral spinal fluid pressure in neuro­ in upright neurosurgical patients: Detection and localization by surgery. ANESTHESIOLOGY 37:510-517,1972 two-dimensional transesophageal echocardiography. ANES­ 7. Tarkkanen L, Laitinen L.Johansson G: Effects of d-tubocurarine THESIOLOGY 60:353-355,1984 on intracranial pressure and thalamic electrical impedence. 26. Bunegin L, Albin MS, Helsel PE, Hoffman A, Hung TK: Posi­ ANESTHESIOLOGY 40:247-251, 1974 tioning the right atrial catheter: A model for reappraisal. ANES­ 8. Campkin TV: Isoflurane and cranial extradural pressure. A study THESIOLOGY 55:343-348, 1981 of neurosurgical patients. Br J Anaesth 56:1083-1086, 1984 27. Matjasko J, Petrozza P, Cohen M, Steinberg P: Anesthesia and 9. Adams RW, Cucchiara RF, Gronert GA, Messick JM, Michenfelder surgery in the seated position: Analysis of 554 cases. Neuro­ JD: Isoflurane and cerebrospinal fluid pressure in neurosurgical surgery 17:695-702, 1985 patients. ANESTHESIOLOGY 54:97-99, 1981 28. Standefer M, Bay JW, Trusso R: The sitting position in neuro­ 10. Grosslight K, Foster R, Colohan AR, Bedford RF: Isoflurane for surgery: A retrospective analysis of 488 cases. Neurosurgery neuroanesthesia: Risk factors for increases in intracranial pres­ 14:649-658, 1984 sure. ANESTHESIOLOGY 63:533-536,1985 29. Black S, Ockert DB, Oliver WC, Cucchiara RF: Outcome following 11. Brain Resuscitation Study Group: Randomized survivors of cardiac posterior fossa craniectomy in patients in the sitting or horizontal arrest. N Engl J Med 314:397-403, 1986 positions. ANESTHESIOLOGY 69:49-56, 1988

-8- LESSONS FROM ON HIGH by Thomas F. Hornbein, M.D. SPECIAL ARTICLE

Anesthesiology 74:772-779,1991

The 28th Rovenstine Lecture: Lessons from on High

Thomas F. Hornbein, M.D. *

MY TITLE for the 28th Rovenstine lecture, "Lessons a resident to death. He gets three years of hell from me, and then, from on High," is a presumptuous perturbation of that if he wants, he can go out and make that fifty thousand a year.' used by Sir Joseph Barcroft for his classic volume describ­ The author of the article goes on to say that Rovenstine ing extensive research on man at high altitude, Lessons is more interested in physicians who, like himself, take from High Altitude.1 Barcroft is the person who described less lucrative academic positions and devote themselves the maternal environment of our beginnings as Mount to research and teaching. Everest in utero. His writings were among those that That dedication to the development of our specialty shaped my own life. Actually, a somewhat more accurate and the pursuit of understanding fits well with the next description of my goals today might be the addition of anecdote I share with you, which is more relevant to my "Questions from on High," for there are as many of those purpose today. This is from a chest surgeon who had been as answers at this stage. through World War II and the Battle of the Bulge with I am immensely honored to be invited to speak before Rovenstine and who was extolling his contribution to de­ this spacious gathering of colleagues, students, teachers, creasing the morbidity and mortality associated with tho­ a shrinking group of mentors, and others of you. As will racic surgery, which heretofore had been an exceedingly become increasingly the case with these events as the years high-risk procedure. The surgeon spoke of a case in a go by, I am among those who never knew or met Emery New York hospital on which both he and Rovenstine were Rovenstine, but I have felt his paternity in the evolution called in after it looked fairly certain that the patient was of our specialty through the teachings of his students, going to die.* He said: some of whom are members of this audience. I was curious about Dr. Rovenstine, and, in particular, wondered about It's something to work with Rovey. He's willing to experiment, his perspectives on my theme for today. Although I have to take a risk if it will advance medicine and possibly save a life. not made a scholarly review of his life, I did discover a Rovey and I had that patient on the table, working on him, for seven hours and twenty minutes, and when we finished, his blood series of articles that appeared as "Profiles" in The Nexv pressure was a hundred and twenty over sixty, and he was talking. Yorker in the fall of 1947.| Rovey was responsible for that. All I had to worry about was my Of the many things that caught my attention, I share cutting and my repairing. When it was over, Rovey said to me, two with you. The first is purely a historical note and 'That's the kind of surgery I like.' provides a glimpse of his personality*: Emery Rovenstine's willingness to "take a risk" ex­ Rovenstine's residents received room, board, and only from thirty- emplifies the theme of my comments. Risk is an inextric­ five to seventy dollars a month—far less than even the moderate able part of our professional lives. Our effective function salaries of nurses, and they worked longer hours. Now, however, a resident at Bellevue draws as much as a hundred dollars a month. is influenced at times by our ability to accept risk. As an 'The money is all gravy anyway,' Dr. Rovenstine has said. 'I see academic physician, I target risk-acceptance in respect to to it that they don't get any time to spend it. I believe in working two areas critical to our ultimate practice of anesthesiol­ ogy: research and residency training. My bottom line is that risk is an essential dietary constituent in medicine, •Professor and Chairman. particularly in our specialty. Received from the Department of Anesthesiology, University of In 1963 I was a member of the first American expe­ Washington, Seattle, Washington. Accepted for publication January dition to climb Mount Everest. Some of us had the hope 11, 1991. Presented at the annual meeting of the American Society of climbing to the top by a new way, up the West Ridge, of Anesthesiologists, October 16, 1989. and perhaps even traversing down the classic way, the Address reprint requests to Dr. Hornbein: Department of Anesthe­ siology, RN-10, University of Washington, Seattle, Washington 98195. South Col Route. As we gravitated by our personal choices Key words: Anesthesia: risks. Rovenstine Lecture. to our preferred routes, we even began to refer to our­ t Murphy M: Anesthesiologist: I. The Cold and Drousy Humour. selves as "Ridgers" and "Colers." This dual goal, two The New Yorker, Oct. 25, 1947, pp 36-45 groups aspiring to climb the mountain by two different Murphy M: Anesthesiologist: II. Drugs, Medicines, and Notions. routes with vastly different levels of uncertainty, provided The New Yorker, Nov. 1, 1947, pp 33-43 Murphy M: Anesthesiologist: III. The Patient is Doing Well. The the stage for Dick Emerson's research. Dick was a pro­ New Yorker, Nov. 8, 1947, pp 38-51 fessor of sociology at the University of Cincinnati at the

772 LESSONS FROM ON HIGH 773

-5 -4 5 -2 0 1 2 3 ( I) A) Date.9F/xiii JLTime. lk- _Location_ TODAY Travel 1 *S ->> STi^J _Tradc (B-G) I \h% %£ I felt (weak-str) 2 I now feci (tired-rested). I Weather (B-G) : during the day 3 ; This moment J Terrain was: (dangerous-safe) I , (diffi-eay) —/ Associates: ^ u'j._B£ Team prog (B-G)jt^ TOMORROW Feel (weak-str) ]J3. Weather (B-G) -*/I Terrain: (danger-safe) -7-/3 . (diffi-easy) -V ^ I feel now (appreh-expec) %L If possible I: (should; will-would FIG. 1. Page from the author's diary on May ifke tn)- re^tU s'*•"'*+ *-f M. 21, 1962, Camp 5W on Mount Everest, the s. a/. night before final summit attempt. ™ ^ '$ enthus is within this "low-high" guess: (3B) (L-H): EcJL 3-. Ew_$L _£L Et_X _*£_ NuJ^l. z2=. LhziL iJL He sees chance of F-S within this low-high guess: (F-S): Ec_J ±_ Ew_I* _L Etr2. _iL Nu^£ z2^ Uizl A_. Today mountains seem (0-5): Remote & , peaceful / , brood­

ing / __L tranquil L , impersonal 0 , exhilarating. menacing_j2,_ quiescent. / punishing_^i

Pers Morale (L-H) : of WU ;of DB a Diary (annoy-pleasant) time, subsequently to join me as a colleague, friend, and level of motivation. Second, information gleaned from climbing companion at the University of Washington be­ the environment and exchanged among individuals serves fore his death from cancer in 1982. One of our daily to maximize uncertainty—that is, to keep the outcome chores on the expedition, to abet Dick's then mysterious in doubt. For example, on the twice-climbed Col Route, inquiry, was to fill in the blanks on each day's page of an the mountain offered more encouraging signals. To max­ indestructible diary. On a scale from —5 to +5 we were imize uncertainty, therefore, the information exchanged to record our hopes, our moods, and our optimism and among individuals would tend to be more pessimistic. For pessimism. For example, on May 21, 1963, the evening example, someone might say, "Looks like a storm brewing Willi Unsoeld and I spent on an airy narrow perch prior off to the west. That may cause us trouble." On the West to climbing to the summit the next day, I dutifully re­ Ridge, which came well supplied with as much environ­ corded these feelings (fig. 1). mental uncertainty as one might desire, the communi­ The two bits of information I call to your attention are cation tended to take on a more optimistic note, all de­ my enthusiasm for the several alternative endeavors signed to keep the outcome maximally in doubt. How did available to us—that is, my motivation: I assigned a +4 it all work out? to +5, near total commitment, to the West Ridge route First, motivation, (fig. 2): Over time each team was un­ and the traverse. My assessment of chances of success: —2 derstandably more committed to its own endeavor than to 0, close to but a little on the pessimistic side of maximum to that of the other group. While various events caused uncertainty, far from either certainty of success or cer­ minor perturbations in motivation, the basic commitment tainty of failure. remained, and indeed the motivation of the Ridgers even Emerson's hypothesis,:}: we learned afterward, had two increased, perhaps in part because of being number two components. First, motivation is maximized by uncer­ in the pecking order. tainty: the more the outcome is in doubt, the greater the Regarding uncertainty (fig. 3): The Colers tended to be more to the optimistic side of maximum uncertainty, but they were certainly less confident of their own success % Emerson RM: Mount Everest: A case study of communication than were we who were not invested personally in their feedback and sustained group goal striving. Sociometry 29:213-227, 1966. University of Washington Department of Sociology, Seattle, goal. On the West Ridge Route, though, the Ridgers 1965. managed to keep their motivation charged by sustaining Anesthesiology THOMAS F. HORNBEIN 774 V74, No 4, Apr 1991

SOUTH COL GOAL: Self-Ratings on Motiuation, by Team and by As I present risk as an essential dietary constituent, time period (Averaged within 10-Day Periods) how do I justify espousing such a point of view to all of us whose goal in life is to minimize risk for our patients? Scale Time Periods Values As human beings and as physicians we are programmed almost from the beginning to minimize risk, to strive for safety and security. We strive through education and occupation to be self- sustaining human beings, seeking security for ourselves and our families, a safe haven, freedom from worry, all those things that are the antithesis of uncertainty. As anesthesiologists we strive to provide safe passage for our patients, to minimize their risks. We practice defensive

SOUTH COL GOAL: High end low Estimates of Likely Outcome, by Team and by Time Period (Rueraged)

UJEST RIDGE GORL: Self-Ratings on Motiuation, by Team and by time Period (Rueraged within 10-Day Periods) Scale Time Periods Values

Scale Time Periods Values 123456789

- Col Team

- WR Team

FIG. 2. Average level of motivation of members of the 1963 Amer­ ican Mount Everest Expedition over the duration of the climb. Top: Motivation on the South Col route of those attempting it ("South Col- ers") and those committed to an alternative route ("West Ridgers"). Bottom: Motivation of each group for West Ridge route. Maximum motivation = +5; maximum disinterest = -5.

UJEST RIDGE GOAL: High and LOUJ estimates of Likely Outcome, by near maximum uncertainty; the Colers, looking at us, in­ Team and by Time Period (Rueraged for lu-Oay Periods) creasingly began to doubt mightily our ability to pull it off. Scale Time Periods The message here? Uncertainty is an essential ingre­ Values 1 2 3 4 5 6 7 8 9 dient to motivation, to accomplishing any difficult task or Succeed Col Team goal. Although not all that is uncertain involves risk, un­ 5 WR Team certainty is an essential element of risk. According to the Oxford English Dictionary,2 to risk 3 2 is to expose to the chance of injury or loss. There are 1 ^ ^~ three elements to this definition. The first is to expose, -1 ^ which implies a choice. You can take it or leave it. In -2 other words, a decision is made to opt in, to gamble, based upon the perception that what is to be gained justifies the possibility of loss. The second element is chance, the pos­ sibility of loss. If loss or injury is certain, that is not risk; there is no uncertainty. Here is where risk and Emerson's FIG. 3. Average assessment of chances of success by members of the uncertainty principle regarding motivation come to­ 1963 American Mount Everest expedition over the duration of the gether. The third element, by now obvious, is injury or climb. Top: Chances of success or failure on the South Col route as assessed by those attempting it ("South Colers") and those committed loss. What is being laid on the line if one fails may range to the West Ridge route ("West Ridgers"). Bottom: Chances of success from a small hurt to permanent injury or loss of livelihood or failure on West Ridge route. Certainty of success = +5; certainty or life. of failure = -5; maximum uncertainty = 0. Anesthesiology V 74, No 4, Apr 1991 LESSONS FROM ON HIGH 775

medicine, risk management, to minimize risks to our­ its blood-pressure cuff and a finger on the pulse of a spon­ selves. Some modern societal law of thermodynamics taneously breathing patient, was awesomely simple com­ seems to be driving our western world toward a demand pared with the intimidating sophistication and complexity for a guaranteed, conception-to-grave, risk-free world. of our current work station, with its delivery system, dis­ We are all too familiar with the medicolegal consequences plays and sensors, alarms and evolving artificial intelli­ of this attitude in our own country today. gence to guide our ministrations, to short-stop our fatigue Maybe we can view risk like we would a drug—bene­ and, to a modest but evolving degree, to troubleshoot ficial to the organism in the proper dose. Too much or and protect us from its own complexity. This sophistica­ too little may be harmful, somewhat like oxygen phar­ tion has allowed us to translate the physiology and phar­ macologically. In defining the range of therapeutic dose, macology learned earlier as concepts into care of patients we must distinguish between timidity at one extreme and so ill that three decades ago they were simply not operated risk-seeking at the other, with risk-acceptance somewhere upon. The practice of critical care medicine has evolved between. One of the major provisos of proper dose is that from our role in the operating room. while one is willing to accept necessary risks, at the same What has happened to anesthesiology as it has come of time long-term survival is enhanced by avoiding as much ,age is far more than technology, though. We now attract as possible those that are unnecessary. Bertrand Russell among the brightest and best medical school graduates points out3: and have earned respect from our peers in other special­ ties, the absence of which for many years affected our A life without adventure is likely to be unsatisfying, but a life in which adventure is allowed to take whatever form it will is likely own self image. We enjoy a practice of medicine that may to be short. be more scientifically based than most, thanks to tech­ nology and our ability to measure and titrate the care of In our profession, especially in anesthesiology, I see very sick people. For example, we have become virtuosos the willingness to risk as essential, not simply as a seasoning at upping and downing and lateraling the cardiovascular to life but to effective function, as for example to the system: we can increase inotropy or decrease it, and like­ ability to be instantly decisive in the presence of a surfeit wise the heart rate; we can alter vascular tone, even to of uncertainty during a moment of crisis. We have all some degree differentially for different vascular beds. experienced such moments in our anesthetic practice. In­ What we can do with what we think we know is awesome. herent in the capacity to accept risk is the ability to accept Our decisions are based increasingly on sound physiologic failure, space within one's self image to be less than the principles and logical assumptions as to what is best. But omniscient, omnipotent creature that we as physicians are what is best? How do we know? programmed to be or sometimes even program ourselves Let me offer an illustration. Twenty-one years ago at to be. The lack of the capacity to accept being less than this same event, Herman Rahn, head of the Department perfect, even while striving for perfection, underscores of Physiology at the University of Buffalo, spoke elo­ the fact that our patients are not the only ones at risk quently about how the pH of cold-blooded animals cor­ when we practice medicine. Those of you who have been related with the decreasing tendency for water to disso­ put through the wringer of malpractice litigation know ciate to hydronium and hydroxyl ions as temperature whereof I speak. Suicide is not an unknown outcome of decreased. Application of this observation to us homeo- such stresses. And as a specialty we certainly seem to be therms has resulted in an approach to pH regulation for winning the substance abuse marathon hands down. patients made hypothermic for cardiac or other surgery. By preserving the usual buffering configuration of the Risk and Research histidine molecule, Rahn proposed that the normal pH As one does not measure time so much by looking in should become more alkaline as temperature falls, rather the mirror as by watching one's children grow, so can I than remaining at 7.4, the normal value at 37° C. A look back over these three decades of my own anesthesia growing literature has begun to explore the physiologic practice and marvel at the incredible maturation of our consequences of pH control during hypothermia, exam­ specialty, fully recognizing that its birth and adolescence ining effects upon the heart and the brain. What is not antedate my entrance into the scene by more than a cen­ known is the bottom line: Does it matter? What pH is tury. What has brought about this change is research and best? Is either of these alternatives optimal? These are its current handmaiden, technology. different from questions concerning what happens to ce­ One of my early-acquired talents was to pass a safety rebral blood flow or cardiac output or myocardial con­ pin through the lead cap of a can of ether with sufficient tractility, even though we think we can assign a goodness skill so that the ether would drip out fast enough onto or badness value to such changes. We possess little knowl­ the gauze-covered mask to allow my patient to go to sleep, edge as to whether the patient is improved or harmed. but not so fast as to drown him. That environment, with Under what circumstance is the outcome best? Anesthesiology 776 THOMAS F. HORNBEIN V74, No 4, Apr 1991

This same query can be applied to an unending array is a gain for society separate from addition to our collective of clinical questions. How much can we let the hematocrit wisdom. But for the energy committed to this objective safely decrease now that the risk of acquired immuno­ to be meaningful, experienced guidance, feedback, and deficiency syndrome (AIDS) from blood transfusion is part critique are needed. To provide such help, if research is of our concern? Are opiates truly better for patients with to be part of the training experience, is, I believe, an heart disease? Does the coronary steal of isoflurane matter? obligation of our training programs and their qualified Although we can administer anesthesia without nitrous faculty. oxide in this day and age, is that really better? What are Finally, a chosen and dedicated few are challenged by the trade-offs between the benefits and costs? These are the pursuit of fundamental understanding. At times this simple questions to ask but difficult, and sometimes im­ research will address important clinical questions. At other possible, to answer. They are outcome questions, at­ times the ultimate utility will be no more than a futuristic tempting to provide information on whether the things fantasy, such as anesthetic-receptor interactions or how we do to benefit our patients actually help, possibly harm, opiates and inhalation anesthetics work to create the or really do not matter very much. anesthesia state in its varied complexity. Again quoting The first research challenge I see ahead of us, therefore, from Medawar, this time in The Art of the Soluble5: is to move beyond theoretical extrapolation from physi­ Science is above all else an imaginative and exploratory activity, ologic observation to assessment of how a particular ap­ and the scientist is a man taking part in a great intellectual ad­ proach affects outcome. Outcome studies are not easy venture. Intuition is the mainspring of every advancement of (not that any good clinical studies are). They require learning, and hairing ideas is the scientist's highest accomplishment; thoughtful design, careful statistical analysis to account the working out of ideas is an important and exacting but yet a lesser occupation. Pure science requires no justification outside for contributions of other variables, and often a large itself, and its usefulness has no bearing on its valuation. population of patients of the appropriate variety. These are studies that can be done only in the clinical setting; We need a few among us willing to pursue what Lionel they often require collaboration across institutions to ob­ Terray, a famous French mountaineer, referred to as the tain a sufficient patient population. They are difficult and "conquest of the useless," in this instance the pursuit of costly and therefore should be targeted to important understanding simply to understand. More and more, as questions. basic research probes the innards of the cell and the be­ The second research goal, which perhaps I should have havior of molecules, we clinician-scientists will need to mentioned first, is that we identify and invest our re­ collaborate with basic scientists to seek increased under­ sources and energy in things that count, whatever the standing of such things as how anesthetics work and how nature of the research. Sir Peter Brian Medawar put it our special pharmacology may serve as a tool for exploring this way in Advice to a Young Scientist4: fundamental biologic processes. Research, especially important research, requires major It can be said with complete confidence that any scientist of any commitment. And when the research is to test hypotheses, age who wants to make important discoveries must study important prob­ rather than simply to describe what happens, then it car­ lems. Dull or piffling problems yield dull or piffling answers. It's ries appreciable risk. Most who have pursued such inquiry not enough that a problem should be 'interesting'—almost any problem is interesting if it is studied in sufficient depth. have experienced the disappointment of finding months or even years of effort down the drain when their pet As we bemoan the seemingly increasing difficulty we hypothesis doesn't pan out. Yet at times we are rewarded face in competing for National Institutes of Health (NIH) serendipitously, finding something important that was not funds or other sources of support, we need to ask ourselves in our original thinking whatsoever. what anesthesiology's important questions and concerns The willingness to tolerate uncertainty, to invest im­ are and ask also where they fit into the larger universe of mense effort with the outcome very much in doubt, is an biomedical inquiry. How much of a finite resource can integral aspect of this type of research. We heard some we justifiably command? Where, for example, does the of the fruits of such commitment when Jack Michenfelder question of optimum hypothermic pH fit relative to issues spoke in 1988 about protection of the brain from hypoxic such as AIDS, malnutrition, cancer, heart disease, acci­ injury,6 and we can find it as well in the contributions of dents, drug dependency? many others as, for example, the recipients of the ASA Third, I see another purpose for research by anesthe­ Award for Excellence in Research, John Severinghaus, siologists, even when the question being addressed may Ray Fink, Francis Foldes, and Ted Eger (and Michen­ be of modest importance, perhaps even verging on the felder himself in 1990) and others yet to come. Our clin­ piffling. If the experience of doing research can help ical practice has been extended and our specialty enhanced young anesthesiologists to learn to think more critically, by the insatiable lust to know and the willingness to risk more questioningly, of what they know and see, then there of individuals such as these. Anesthesiology LESSONS FROM ON HIGH 777 V 74, No 4, Apr 1991 Risk and Training TABLE 1. Personality Attributes of Anesthesia Trainees (Type As)

Finally, and more speculatively, I would like to explore Satisfactory Performers Poor Performers some thoughts on risk-acceptance as it might relate to the Independent Timid, cautious selection and training of anesthesiologists. Himalayan Dominant Feelings of inadequacy mountaineering has been characterized as hours of sheer Decisive Unsure Calm Tense (albeit breathless) boredom, punctuated by moments of Emotionally stable Emotionally unstable stark terror. This same assertion has also been applied to Self-control Undisciplined the administration of anesthesia. In both instances, the Cooperative Cunning Conscientious Self absorption boredom-terror analogy, albeit attention-getting, is an Detached Frustrated oversimplification of reality as well as an undervaluation High standard Irritable of what represents our usual and customary function. Our Likes results, serious function has also been compared to that of airplane pilots From Reeve PE,7 with permission. with hours of conventional flight (in anesthesia the low- risk patient and procedure) versus moments of intense, decisive action. While managing a steady state of anes­ such categorization as too simplistic, pointing out the thesia demands certain attributes, among them the vigi­ spectrum between risk seekers and risk acceptors. He re­ lance that is contained in our Society's emblem, the ca­ sponded by sharing more of his assessments with me.§ I pacity to function well in moments of crisis is, I believe, found the characteristics that Dr. Ogilvie has discerned a critical characteristic for the anesthesiologist, and indeed in type Ts, individuals such as race-car drivers and sky this attribute may to some degree distinguish the practice divers (but distinct from those who are involved in com­ of anesthesiology from many other types of medical prac­ petitive team athletics) surprisingly similar to the attributes tice. we have just examined (table 2). Like most of you in this room, I cherish a collection of Dr. Ogilvie points out that these individuals possess hypotheses, or biases, as to what attributes make for a "positive personality organization," coupled with the need good anesthesiologist, even while as an educator of anes­ to test physical, emotional, and intellectual limits. The thesiologists I am impressed by the broad spectrum of type Ts that he studied scored within the top 5-25% of personality traits that are seemingly compatible with be­ the general population in regard to these values. If you coming competent. I underscore seemingly, for in fact we scan this list carefully and compare it with our type As, really don't have much information on the issue. Some where "A" in this instance stands for anesthesiologist, individuals seem to be naturally endowed with the right one sees striking similarities between thrill seekers and stuff. Most of us exhibit an impressive capacity to learn. anesthesiologists. Among common attributes are some But to stay cool under fire is not everyone's cup of tea. that may define the capacity for functioning well in mo­ Can we assess the lack of enough of this capability pro­ ments of high stress, such as decisiveness and the ability spectively? Can we do a better job of helping people to to remain calm, in control, and detached. I underscore learn to function in such situations? Can we develop ways also the type T emotional detachment or "loner" attri­ to measure whether someone has acquired an acceptable bute—the capacity for independent or autonomous func­ capacity at the end of training? This issue has not been a tion—as that at the top of both lists. Anesthesiologists major target for attention, partly because it's a tough one experience a very different kind of medical practice from to deal with. Yet without addressing this question directly, that of other physicians; to a significant extent we find we have somehow managed to garner insights that may ourselves in a lonely setting where we are called upon to be relevant. I have found only one study that has tried to make critical decisions independently, without the op­ characterize anesthesiologists, a work published by Peter portunity for consultation and collaboration. This quality Reeve in Anaesthesia nearly a decade ago.7 Reeve assessed of independence, of autonomous, detached function, a the distinctive personality traits of 44 English anesthesia willingness and ability to "go it alone," may distinguish trainees, 80% of whom performed satisfactorily, but some anesthesiologists from many other medical specialists. of whom didn't do so well (table 1). What does it all mean? For those moments of maximum Recently I—the mountaineering Hornbein, that is— uncertainty when we need our catecholamines appropri­ was interviewed by a reporter writing about risk for a ately enhanced, when all we know and see must be mo­ medical magazine. When the article appeared I found bilized quickly to elicit the right action, when we must myself in the company of individuals characterized as take charge, decide, act and stay cool in the process— "type Ts," "thrill (risk)-seekers" or "stimulus addicts," according to the description of a San Jose State psychol­ § Ogilvie BC: The stimulus addicts. The Physician and Sports Med­ ogist, Bruce Ogilvie. I wrote to Dr. Ogilvie to protest icine 1:61-65, 1973 Anesthesiology 778 THOMAS F. HORNBEIN V74, No 4, Apr 1991

TABLE 2. Personality Attributes of Stimulus Addicts (Type Ts) evaluate how well such lessons are learned? Critical events

Autonomous are rare in our routine clinical practice, and indeed when Will to dominate, lead they do occur the teacher ceases to be a passive observer Decisive, self-assertive and becomes actively involved in the care of the patient. Low anxiety Maybe again lessons can be learned from the pilot's world, Emotional stability Reliable in this instance from the flight simulator, an expensive Responsible device that can realistically reproduce a whole variety of Emotionally detached/loner events and critical incidents, where "crashes" can be re­ Adaptable, resourceful Energetic peated many times over until lessons are learned. Patients Nonconformity are more complex than planes in their behaviors, and the Creativity, abstract ability capacity to simulate their responses is more problematic. T = Thrill-seekers/stimulus addicts. Even so, simulation might help us to deal with this im­ From Ogilvie BC §. portant aspect of an anesthesiologist's performance that is, one hopes, rare in real life. these are our survival traits. Only in retrospect can we I have touched upon but two points of intersection of take the time to introspect; it's an unaffbrdable luxury in anesthesiology with risk acceptance. I know now that risk the midst of a crisis. Yet we must continue to process new is as much a part of my professional life as an anesthe­ information and be willing to formulate new plans and siologist as it is of my extraprofessional one as a mountain new actions even in the heat of battle. That's an awesomely climber. I know that as a climber some risk, but only an high order of function. We should not be surprised that acceptable dose, is an essential element to the endeavor. even the best of us don't pull it off perfectly all the time. "Uncertainty maximizes motivation," Dick Emerson (And often in our game we don't even know how to define taught me. Did I choose my specialty for similar reasons? perfection in these situations.) For our patients, though we wish it otherwise, risk is in­ Is it surprising, then, that some might be less well suited separable from their encounters with the medical estab­ for this type of function than others? How much does it lishment. Among the reasons, particularly for our spe­ matter? Can we discern an effect on performance or on cialty, are the inevitability of human error, of machine outcome? I return to the airplane analogy. In the early failure, of not knowing enough either individually or col­ 1970s Thomas Neuman developed for the Royal Swedish lectively, or simply of patients' not always responding in Air Force the Defense Mechanism Test, a selection pro­ ways that fit with what we do know. Risk is a real and cedure that differed radically from the conventional cog­ ever-present part of all our lives. We might wish at times nitive and psychomotor tests than in general use.lf This to control the dose, but that, by definition, is not possible. test evaluated a person's perceptual defense organization, That which we cannot control we must either accept or that is, his psychological defense and coping mechanisms try to avoid. The control that one seeks is not of risk, in response to a threat, his adaptive style. Over the next then, but of oneself in living with and coping with risk 15 years this test was validated in respect to pilot perfor­ and its attendant uncertainty. It is as if in this act of ac­ mance, pass/fail rate of trainees, and frequency and se­ cepting uncertainty we transfer risk from the bodies and verity of critical incidents. Subsequent use of the test to lives of our patients to ourselves. In the process we both screen applicants succeeded in reducing failure rates of benefit. trainees and proved a predictor of pilot accident prone- I share with you a relevant comment by a Seattle neu­ ness. rologist, Robert Colfelt, who for some time was the elo­ Can a similar approach be applied to the screening and quent editor of our local medical bulletin**: selection of anesthesiology trainees? Should it? Even the If we are not careful we become too comfortable living within the asking of the question represents a significant departure abstractions of patient care, and become neglectful of each person from our current approach to specialty choice and there­ in their uniqueness. . . . What allows us to escape those traps is fore feels threatening. But perhaps now our specialty has our capacity for imagination, re-imaging our lives and our work as physicians. This means that we have no choice but to change achieved sufficient maturity in regard to its role in patient our lives and keep the possibilities of being more than we are and care that societal responsibility demands that we gain a different than we have ever been. As we climb higher in our jour­ better handle on how well we do in preparing physicians neys our falls are farther and more painful. When we don't want for careers in anesthesiology. To what extent can we train to get hurt we stay on level ground and out of harm's way. But people to this high level of performance? And can we we wanderers go where we must go and do what we must do. We pay high prices because we make plenty of mistakes in the process.

11 Referred to in a presentation by Dr. R. B. Lee at the symposium on "Safety in the Operating Theatre: The Human Factor," University ** Colfelt R: Mystery and medicine. King County Medical Society of Melbourne Faculty of Medicine, Australia, August 5-6, 1983. Bulletin 66:8, 1987. Anesthesiology LESSONS FROM ON HIGH V74, No 4, Apr 1991 779

Or as Alfred North Whitehead put it: Until one is committed there is hesitancy, a chance to draw back, always an ineffectiveness. Concerning all acts of initiative (and Periods of tranquility are seldom prolific of creative achievement. creation), there is one elementary truth, the ignorance of which Mankind has to be stirred up. kills countless ideas and splendid plans: that the moment one def­ initely commits oneself, then Providence moves too. All sorts of As I reflect on what I know and see and, more than things occur to help one that would never otherwise have occurred. that, upon what I don't know and do not see and do not A whole stream of events issues from the decision, raising in one's understand, I have come to believe that there are occa­ favour all manner of unforeseen incidents and meetings and ma­ sions when our commitment is complemented in inexpli­ terial assistance, which no man could have dreamt would have come his way. I have learned a deep respect for one of Goethe's cable ways by what one might call luck. In our acts we couplets: find ourselves transported beyond what we know and see, beyond ourselves. Whatever you can do or dream, you can begin it. During our traverse of Everest, as we descended from Boldness has genius, power and magic in it. the summit down the South Col route, Willi Unsoeld and I spent a night out with Barry Bishop and Lute Jerstad, References whom we overtook in the dark. In 1963, to bivouac above 28,000 feet without oxygen would have been regarded 1. Barcroft J: The Respiratory Function of the Blood: I. Lessons as unsurvivable, yet it was a nearly windless night that we from High Altitudes. London, Cambridge at the University shivered through, continuing down the next day. At a Press, 1928 2. Oxford English Dictionary. Oxford, Oxford University Press, 1971 reception in Kathmandu a short time later, I remember 3. Russell B: In MacCrimmon KR, Wehrung DA: The Management commenting to a Nepalese dignitary upon how lucky we of Uncertainty: Taking Risks. New York: The Free Press (Di­ were to have succeeded in our traverse and to have lived vision of MacMillan, Inc.), 1986, p 3 to tell about it. His rejoinder was, "Luck is what you make 4. Medawar PB: Advice to a Young Scientist. New York, Harpter it." And mysterious as it may seem, I have come to believe Colophon Publishers, 1979, p 13 5. Medawar PB: The Art of the Soluble. London, Methuen, 1967, that there is a message to be heeded in his comment. p 116 W. H. Murray,"}"}* an English mountaineer of half a cen­ 6. Michenfelder J: The 27th Rovenstine Lecture: Neuroanesthesia tury ago, put it thus: and the Achievement of Professional Respect. ANESTHESIOL­ OGY 70:695-701, 1989 •f-j- Murray WH: In Hornbein TF: Everest, the West Ridge. Seattle, 7. Reeve PE: Personality characteristics of a sample of anaesthetists. The Mountaineers, 1980, p 56 Anaesthesia 35:559-568, 1980

-9- CLINICAL CHALLENGES FOR THE ANESTHESIOLOGIST by Robert K. Stoelting, M.D.

SPECIAL ARTICLE

Anesthesiology 74:1129-1136,1991

The 29th Rovenstine Lecture: Clinical Challenges for the Anesthesiologist

Robert K. Stoelting, M.D.*

I AM DEEPLY HONORED and privileged to be chosen to of Wisconsin in 1930, and it was Dr. Guedel's recom­ present the 29th annual Emery A. Rovenstine lecture. I mendation that directed Dr. Rovenstine to Dr. Waters. am not of the generation of anesthesiologists who can I view this lecture as an opportunity for me to describe describe personal memories of this giant in our specialty. to you how I perceive certain aspects of our specialty. It Nevertheless, I, like all of you, continue to benefit from is a frightening and humbling experience, however, when his early vision and dedication to our specialty. Perhaps one considers the challenge of such an opportunity. What I can claim some indirect influence from Dr. Rovenstine, could I possibly say that would merit your attention and as both my father and I trained under Dr. Stuart C. Cul- at the end of my comments deserve a polite round of len, who was one of Dr. Rovenstine's early residents. I applause? would also be remiss if I did not point out that Dr. Roven­ After much reflection, I concluded that my thoughts stine was a native of my home state and a 1928 graduate would be best directed toward my view of education in of Indiana University School of Medicine, ranking third anesthesiology as it relates to clinical practice, and thus in a class of 92 students. It is also reassuring that Dr. my chosen topic—Clinical Challenges for the Anesthe­ Rovenstine earned a passing grade by examination for siologist. If I have made an impact, on anesthesia educa­ his anesthesia experience as a medical student. tion, I would hope it is in the area of condensing clinically We Hoosiers often brag about our basketball teams, relevant information into a textbook format that provides but I doubt if many of you know the role this game played a rapid and accurate source of information for both the in Dr. Rovenstine's eventual pursuit of a career in anes­ trainee and practitioner. The continuum of anesthesia thesiology. As described by Dr. Solomon G. Hershey in education is a life-long process, and anesthesiologists must his 1982 Rovenstine lecture, Rovey was an outstanding never lose their zeal to be students. We live in an era of high school athlete.1 During his senior year in high school, information explosion, which has been characterized by young Rovenstine became exasperated with a referee some as information pollution. Some questions are dis­ whom he felt was always in his way when he had the ball. sected beyond recognition; others are virtually ignored. To show his displeasure, Rovey butted the referee in the New knowledge must be incorporated into daily activities, stomach. According to legend, the referee, a large man, as personal experience is not enough. Indeed, personal picked up the young athlete and spanked him. This ref­ experience, which is often characterized as clinical eree was also a physician on the faculty of Indiana Uni­ impression, may be both invaluable and at the same time versity; his name was Dr. Arthur E. Guedel, the distin­ misleading—misleading because control observations are guished anesthesiologist who first described the planes absent and memories are highly selective. Acceptance of and stages of ether anesthesia. new information or reinterpretation of old information This chance meeting during a high school basketball may be resisted, as added benefits to currently accepted game led to a lasting friendship and might be considered approaches may be difficult to document. It is almost trite the event that launched Emery A. Rovenstine on his bril­ to say that knowledge is endless and constantly changing. liant career in anesthesiology. Indeed, Dr. Rovenstine be­ With this in mind, I would like to propose the following came one of the first two anesthesia residents appointed four principles for those of us who consider ourselves to by Dr. Ralph Waters when he arrived at the University be life-long students of anesthesiology: seek cause-and- effect relationships in decision-making; periodically re­ evaluate traditional but unproven concepts; establish re­ * Professor and Chairman. Received from the Department of Anesthesia, Indiana University alistic priorities in dealing with available information; and School of Medicine, Indianapolis, Indiana. Accepted for publication be receptive to new information and technology. These November 20, 1990. four principles should apply equally to those who are in Address reprint requests to Dr. Stoelting: Department of Anesthesia, residency training, those who consider themselves edu­ Indiana University School of Medicine, Indianapolis, Indiana 46202- cators, and most important, that largest group, those who 5115. Key words: Anesthesia, history. Anesthetics, volatile: isoflurane. are in the active practice of delivering anesthesia care to Liver: hepatitis. Neuromuscular relaxants: succinylcholine. patients on a daily basis.

1129 Anesthesiology 1130 ROBERT K. STOELTING V74, No6,Jun 1991

I am going to discuss various issues in current anesthetic observed an incidence of unsuspected liver disease similar practice that emphasize these four principles and thus re­ to that found in the study by Schemel.4 Combining data flect clinical challenges for the anesthesiologist. Specifi­ from these two reports results in an incidence of unsus­ cally, I will use as examples of clinical challenges the fol­ pected liver disease of about 1 in 700 previously asymp­ lowing issues: 1) anesthetic-related hepatotoxicity, 2) tomatic adults and an incidence of unsuspected postop­ perioperative myocardial ischemia, 3) nothing by mouth erative jaundice of about 1 in 2,100-2,500 adults. (NPO) after midnight, 4) side effects of muscle relaxants, A report published in 1977 described a case of hepatic 5) premature drug obituaries, and 6) standards of moni­ necrosis after anesthesia with enflurane.6 The only ob­ toring. vious cause appeared to be the anesthetic until a liver biopsy and electron microscopic examination revealed Anesthetic-related Hepatotoxicity cytomegalovirus. One cannot help but wonder how many With respect to the four principles cited above, the other cases of so-called anesthetic-related hepatotoxicity controversy surrounding anesthetic-related hepatotoxicity might have been attributed to other causes had more so­ illustrates the importance of insistence upon documen­ phisticated testing been performed. tation of cause-and-effect relationships in decision-making Why do we insist on better proof before a causal re­ as well as receptivity to new information and technology. lationship is accepted? One obvious concern is that an The rarity of severe hepatic dysfunction after anes­ assertion of a causal relationship impugns the reputation thesia with currently used inhaled anesthetics makes a and may inappropriately decrease application of a useful prospective randomized investigation of a true cause-and- drug. Patients who might benefit from the drug in ques­ effect relationship between anesthetic drugs and liver tion or in whom the drug would be the optimal selection damage impractical.2 For example, if the incidence of in­ are potentially deprived of the best care. Furthermore, jury is extremely rare (1 per 100,000 cases), the dem­ the alternative drug may introduce its own unique side onstration of a doubling of such an incidence secondary effects, such as depression of ventilation following opioid to the use of the anesthetic could require the collection administration. Another concern is that acceptance of a of data on more than one million patients. As a result, causal relationship provides a reason to stop looking for the rare injury some drugs may produce becomes iden­ other causes. tifiable only by anecdotal reports of injury that are related It is reassuring that hepatic dysfunction after admin­ in time to the administration of the drug in question. The istration of volatile anesthetics is so rare that its clinical existence of a large number of such reports may suggest significance can rightfully be questioned. Indeed, the in­ a causal relationship, particularly if the associated findings cidence of alleged isoflurane-induced hepatic dysfunction, are considered to be unique. In this regard, chills, fever, based on anecdotal case reports, is lower than the spon­ nausea, and eosinophilia occurring postoperatively in a taneous incidence of viral hepatitis, leading some to ques­ middle-aged obese woman previously exposed to halo- tion the need for dwelling on this topic.7 Be aware, how­ thane have been proposed as a unique picture of halo- ever, that there is new information that the clinical anes­ thane-induced hepatitis.3 An unproven assertion is that thesiologist must continue to assimilate. For example, enflurane and isoflurane, because they are also haloge- recently developed and more sensitive technology dem­ nated hydrocarbons, would predictably produce a syn­ onstrates that patients with halothane hepatitis may gen­ drome similar to that attributed to halothane. erate antibodies toward a covalently bound metabolite of 8 Case reports as a mechanism to prove cause-and-effect halothane. These antibodies, formed in response to ox­ relationships have many limitations. Proof by analogy is idative metabolites of halothane, are also produced to a the weakest way of demonstrating an association, as the lesser extent after administration of enflurane and isoflu­ absence of a control group eliminates any scientific cred­ rane. Indeed, it has been demonstrated that enflurane ibility concerning a cause-and-effect relationship. Exam­ metabolism produces covalently bound liver adducts that ples of the hazards of basing cause-and-effect conclusions are recognized by antibodies from patients with halothane 9 on the basis of chance or temporal association are abun­ hepatitis. The incidence of anesthetic-related hepatic dant in the anesthesia literature. For example, in 1976, dysfunction most likely parallels the magnitude of pro­ Schemel described the incidence of unexpected hepatic duction of these antigenic metabolites, which is least with dysfunction after routine laboratory screening of asymp­ isoflurane, greatest with halothane, and intermediate with tomatic adult patients admitted to the hospital for elective enflurane. operations.4 In this report, 11 of more than 7,000 patients In view of this common mechanism for hepatotoxicity manifested unsuspected liver disease. Surgery was can­ induced by volatile anesthetics and cross-sensitivity be­ celled in these patients, and 3 of the 11 subsequently de­ tween these drugs, it is conceivable that changing halo- veloped jaundice in what would have been the postop­ genated anesthetics for patients requiring multiple ex­ erative period. Wataneeyaweeh et al.,5 in a similar study, posures will not necessarily reduce the risk of anesthetic- Anesthesiology V74,No6,Junl991 CLINICAL CHALLENGES FOR THE ANESTHESIOLOGIST 1131 induced liver injury in the rare susceptible individual. One could also ask how many patients have been sensitized by virtue of a previous uneventful exposure to halothane. Perhaps the future will yield antibody assays for the de­ tection of patients sensitized to volatile anesthetics as well as provide definitive proof when a diagnosis of exclusion is proposed as acceptable evidence for establishment of a cause-and-effect relationship between the anesthetic and liver dysfunction.10 Clearly, the issue of anesthetic-induced hepatotoxicity must still be confronted by the clinical anesthesiologist even in this era of declining halothane usage.

Perioperative Myocardial Ischemia One of the most sacred concepts of cardiac anesthesia teaching is the presumed role of the balance between myocardial oxygen delivery and myocardial oxygen re­ quirements in the development of myocardial ischemia (fig. 1). The clinical anesthesiologist would seem to be following conventional wisdom in avoiding changes that adversely alter this delicate balance when caring for pa­ tients with coronary artery disease. I do not challenge the concept but suggest that a literal acceptance of this equa­ FlG. 2. The incidence of myocardial ischemia increases in anesthe­ tion fails to give proper weight to that event or events tized patients who experience peak heart rates greater than 110 beats per min. When peak heart rates are less than 110 beats per min, the most likely to increase myocardial oxygen requirements incidence of myocardial ischemia is unrelated to heart rate. (Repro­ and produce myocardial ischemia in vulnerable patients. duced with permission.12) For example, Slogoff and Keats postulated that approx­ imately 90% of new myocardial ischemia observed during anesthesia is the manifestation of asymptomatic or silent greater than 110 beats per min (fig. 2).12 When heart rate ischemia observed in patients before operation and that is less than 110 beats per min12 (fig. 2), the incidence of only 10% is related to anesthetic management.11 Since myocardial ischemia is random and silent, being unrelated silent ischemia occurs in the absence of hemodynamic ab­ to heart rate. The fact that most myocardial ischemia oc­ normalities, it is likely that this form of myocardial isch­ curs in the absence of hemodynamic alterations suggests emia, when it occurs, will not be preventable by the anes­ caution in endorsing routine use of expensive and complex thesiologist. monitors solely to detect myocardial ischemia in vulner­ During anesthesia, increases in heart rate seem to be able patients. While increased sensitivity is attractive there the single most predictable event resulting in reversible are no data to confirm that ischemia detected with these causes of myocardial ischemia. Indeed, in anesthetized devices will improve outcome. Likewise, there are no data patients the incidence of myocardial ischemia sharply in­ to show outcome benefit from pharmacologic reversal of creases in patients in whom the heart rate increases to hemodynamically unrelated (i.e., silent) myocardial isch­ emia. The issue of anesthetic-induced coronary artery steal MYOCARDIAL ^ MYOCARDIAL syndrome and perioperative myocardial ischemia in pa­ OXYGEN 'ZZ. OXYGEN tients with coronary artery disease can trace its origin to DELIVERY REQUIREMENTS a report in 1983 by Reiz et al.n At first glance, the title of this paper, "Isoflurane: A powerful coronary vasodi­ Coronary Blood Flow Heart Rate lator in patients with coronary artery disease," suggests Oxygen Content of Blood Pressure goodness for isoflurane, an inhaled nitroglycerin that also produces anesthesia. However, careful reading reveals a Arterial Blood Ventricular Volume different picture. Ten of 21 patients studied by Reiz et Myocardial Contractility al. receiving 1 % end-tidal isoflurane manifested electro­ cardiographic evidence of myocardial ischemia. Patients FIG. 1. The balance between myocardial oxygen delivery and myo­ receiving halothane did not show evidence of myocardial cardial oxygen requirements. Below each are listed events that deter­ mine oxygen delivery or requirements. ischemia. The authors speculated that isoflurane, but not Anesthesiology 1132 ROBERT K. STOELTING V74,No6,Jun 1991 halothane, produced redistribution of coronary blood flow in the majority of the 10 patients, resulting in regional myocardial ischemia—the so called coronary artery steal syndrome.13 This report stimulated a flurry of investi­ gative activity culminating in four reports of the results of laboratory research and an editorial entitled "Is iso- flurane dangerous for the patient with coronary artery disease," all of which were published in the March 1987 issue of ANESTHESIOLOGY.14-18 Some anesthesiologists became reluctant to administer isoflurane to patients with coronary artery disease out of concern that myocardial ischemia might result. Nev­ ertheless, clinical experience as well as observations in many published studies fails to show that isoflurane is dangerous for use in patients with coronary artery dis­ ease.19,20 Indeed, in 1989, Slogoff and Keats reported the results of a randomized trial of primary anesthetic agents on the outcome of coronary artery bypass graft opera­ tions.11 These authors concluded that the incidence of perioperative myocardial ischemia and subsequent out­ come following coronary artery bypass graft operations were not different in patients anesthetized with halothane, FIG. 3. Coronary artery steal is most likely to occur when a drug enflurane, isoflurane, or in those receiving high doses of produces coronary arteriole dilation distal to a site of stenosis, thereby reducing flow through high resistance collateral vessels. This type of sufentanil. vulnerable coronary artery disease anatomy was present in 23% of the The clinical anesthesiologist is thus faced with a di­ patients studied. (Reproduced with permission.21) lemma: should isoflurane be avoided in patients with cor­ onary artery disease out of concern that myocardial isch­ emia might result, or use an alternative approach with its NPO After Midnight own unique risks? I must admit that my strong bias was and still is that isoflurane is a safe and useful drug in most A traditional but unproven practice that is undergoing patients, including those with coronary artery disease. renewed interpretation is the concept of NPO after mid­ Much like the hepatotoxicity question, however, the night and the resulting risk factors for pulmonary aspi­ importance of the coronary steal syndrome story may de­ ration. This issue reflects the principles of periodic re- serve continued scrutiny. I base this comment on a 1988 evaluation of traditional but unproven concepts and re­ report by Bufnngton et al. describing anatomic variations ceptivity to new information. Recently, two important and in patients with coronary artery disease.21 Coronary artery clinically pertinent questions have been posed.23 First, how steal is most likely to occur when a drug produces coronary common is life-threatening pulmonary aspiration in the arteriole dilation distal to a site of stenosis, thus reducing elective surgical patient with no recognized risk factors, flow through high-resistance collateral vessels. As de­ and, second, is it necessary for these healthy patients to scribed by Buffington et al., this pattern of coronary artery abstain from ingesting both liquids and solids for as long anatomy is present in about one fourth of affected patients as current recommendations suggest? Based on both ret­ (fig. 3).21 Clearly, studies combining all patients with cor­ rospective and prospective studies in over 225,000 adult onary artery disease but without considering the anatomy and pediatric patients, it is concluded that the rate of clin­ of the disease will bias results toward the conclusion of ically significant aspiration in healthy patients scheduled infrequent or even no drug-induced effect. for elective surgery is exceedingly low and that mor­ Perhaps Priebe said it best in the concluding paragraph bidity is modest even when the rare aspiration event oc­ of his detailed review of the coronary circulation.22 "The curs.23-25 question has been raised; is isoflurane dangerous for the For example, in a 1986 report Olsson and colleagues patient with coronary artery disease? The answer should described a retrospective examination of over 185,000 be: Yes, it is potentially dangerous in some patients, under anesthesia records of pediatric and adult patients.24 As­ some conditions-an answer that can be applied to all an­ piration was rare but was most often associated with dif­ esthetic agents, and for that matter to all efficacious ficulty in airway management. Most importantly, symp­ drugs." toms from aspiration in these patients were minimal, and vlrfStjun 1991 CLINICAL CHALLENGES FOR THE ANESTHESIOLOGIST 1133

mortality was zero. In 1988, Tiret et al. reported a pro­ of fluid that is 'safe' for elective surgical patients to con­ spective study of more than 40,000 pediatric patients.25 sume with and without premedication."23 Aspiration occurred in four children, and there was one Future studies may result in significant modification of death unrelated to aspiration. Clearly, if one accepts these current fasting guidelines and make anesthesia safer and data, routine pharmacologic prophylaxis designed to alter more pleasant for children and adults. Clearly, this en­ the volume and/or pH of gastric fluid is not warranted. thusiasm for reevaluation of the traditional NPO-after- As correctly emphasized by several authors, the critical midnight concept does not apply to patients at known risk combination of gastric fluid of volume 0.4 ml • kg-1 and for aspiration. Furthermore, solid food is not the same as pH < 2.5 has not and will never be verified in humans. clear liquids. Finally, I cannot leave this issue without a The 0.4 ml • kg-1 figure perpetuated by myself and other reminder that the best protection against pulmonary as­ investigators has its origin in the following statement from piration is maintenance of an unobstructed upper airway the discussion section of a paper by Roberts and Shirley and, when indicated, placement and subsequent removal in 1974.26 "Our preliminary work in the Rhesus monkey of a cuffed tracheal tube by a skilled anesthesiologist. suggests that 0.4 ml • kg-1 is the maximum aspirate that does not produce significant changes in the lung. As this Side Effects of Muscle Relaxants translates to approximately 25 ml in the adult human fe­ I wish to use muscle relaxants as my example of the male, we have arbitrarily defined the patient at risk as the importance of establishing realistic priorities in dealing patient with at least 25 ml of gastric juice of pH below with available information. Specifically, I am alluding to 2.5 in the stomach at delivery." the importance that is attached to the circulatory side Obviously, the scientific validity of this figure in patients effects produced by these drugs. There is no question was not proven by these comments. In fact, there are that the safe use of any drug requires an understanding recent data suggesting that the critical volume in animals of that drug's side effects. At the same time, the relative may be as much as 0.8 ml • kg-1.27 If these results were importance of these side effects must be considered in the to be extrapolated to humans, and I am not necessarily more global perception of the beneficial effects of these suggesting they should be, the critical volume for severe drugs at the neuromuscular junction. aspiration could be increased from 25 to 50 ml, consid­ The so-called modern muscle relaxants represented by erably reducing the number of patients considered to be pancuronium, atracurium, and vecuronium have, in my at risk. opinion, modest and predictable effects or lack of effects What is a reasonable period of time to refrain from on blood pressure and heart rate. My quarrel is not with ingestion of liquids prior to elective induction of anes­ consideration of these effects but rather with the impor­ thesia? Several recent articles as depicted by a report from tance that is placed on them. For example, blood pressure Maltby et al. have challenged the concept of prolonged 28 and heart rate changes attributed to muscle relaxants are fasting before elective surgery. Other reports have con­ usually modest and nearly always transient and often occur sistently demonstrated that clear liquids administered up only with rapid administration of large doses.30 Nev­ to 2 h before the induction of anesthesia do not increase ertheless, these changes may be considered grounds for gastric fluid volume and may actually facilitate gastric avoiding a specific muscle relaxant, whereas similar emptying. For example, in 1988 McGrady and Mac- changes produced by thiopental are rarely discussed. Donald reported that patients given 100 ml of water 2 h Perhaps the cost of the drug rather than modest cir­ before induction of anesthesia had lower gastric fluid vol­ culatory responses deserves the greatest consideration. It umes than did patients who were fasted in the usual man­ also seems ironic that the lack of heart rate effects pos­ ner.29 A consistent finding is that gastric fluid pH and sessed by atracurium and vecuronium is now perceived volume are independent of the duration of the fluid fast by some as a disadvantage when opioid-induced heart rate beyond 2 h provided that only clear fluids are ingested. slowing is likely. Clear fluids that have been studied include water, car­ bonated beverages, clear fruit juice, tea, and coffee. It is Premature Drug Obituaries of interest that a small amount of cream or sugar added to coffee or tea does not appear to cause a delay in gastric Succinylcholine is a classic example, perhaps along with emptying. nitrous oxide, of a drug that has served us well but for I agree with Cote, who, in his recent editorial, stated, which the obituary has already been written. We recite "I believe that we have had enough publications directed long and impressive lists of side effects unique to succi­ at preventing a problem that may not be clinically im­ nylcholine, often without giving proper credit to the de­ portant, and suggest instead that we focus our attention sirable attributes of this drug. I have often wondered how upon fasting guidelines, and the type, timing, and volume the history of anesthesia would have been changed had ROBERT K. STOELTING Anesthesiology 1134 V74, No6,Junl991

succinylcholine's neuromuscular blocking properties been that can be eliminated with proper education and expe­ recognized in 1906, when this drug was studied for its rience. Certainly, early warning of adverse trends is the vagomimetic effects in a curarized frog preparation.31 I most likely result of using pulse oximetry and capnog­ have not experienced the same curiosity in speculating raphy. about the likeliness of approval of succinylcholine if it Anyone who believes that clinical observation is a sub­ were submitted to the Food and Drug Administration in stitute for recognition of arterial hemoglobin desaturation 1990. as measured by pulse oximetry should consider the find­ There is no doubt that the first nondepolarizing muscle ings of Comroe and Botelho in an article published in relaxant that mimics succinylcholine in onset and to a 1947.33 In this report, the majority of 127 observers lesser extent duration of action will replace this valuable ranging from medical students to professors were unable drug. Until that time, however, I emphasize the important to detect the presence of cyanosis until the arterial he­ role this drug plays in our daily practice, with the following moglobin oxygen saturation was about 80%, and one question. If you could have all the monitors, equipment, fourth of the observers could not detect cyanosis even at and inhaled drugs you wish for an anesthetic but only one saturations of 75% or less. Clearly, visual impressions of injected drug, which drug would you select? The correct the presence or absence of cyanosis are unreliable, and answer, in my opinion, is two bottles of succinylcholine. clinical experience makes little difference in the accuracy To those who said thiopental or a similar drug, I will of assessment. grant you runner-up status but point out that only suc­ More recently, a study conducted in children reaf­ cinylcholine allows one rapidly and reliably to ventilate firmed the value of pulse oximetry.34 In this report, 10 the lungs in a patient with a previously closed glottic of 24 episodes of arterial hemoglobin oxygen saturations opening. To those who favor atropine or a vasopressor of less than 73% were undetected without pulse oximetry such as ephedrine, I remind you of the value of the me­ and, as in Comroe and Botelho's report, there was no chanical stimulus provided by the laryngoscope blade. relation between the accuracy of reporting and the ex­ Much like succinylcholine, nitrous oxide is an example perience of the observer. Decreased arterial hemoglobin of a drug with known desirable effects that are often rel­ oxygen saturations preceded changes in skin color or he­ egated to lesser importance when considering adverse side modynamic variables; in fact, changes in heart rate and effects. The long clinical history of safe nitrous oxide use the electrocardiogram occurred in only a minority of pa­ suggests that much of its recently documented toxicity tients experiencing arterial hypoxemia. and concern about trace concentrations are of modest Vigilance alone is not a guarantee of patient safety, clinical importance. It is nevertheless likely that nitrous and monitoring is designed to enhance vigilance and de­ oxide, like succinylcholine, will experience disuse as soon tect adverse trends before they become irreversible. As as a suitable alternative becomes available—specifically, stated in an article in the Journal of Clinical Monitoring, a potent drug with solubility characteristics similar to those it is clear that pulse oximetry and capnography greatly of nitrous oxide. Desflurane and perhaps sevoflurane may contribute to the ability of clinical anesthesiologists to be the drugs that indeed challenge the future role of ni­ recognize undesirable trends or mishaps (fig. 4).35 At the trous oxide. same time, the much-revered value of the oxygen analyzer and electrocardiogram is not supported by that article's Standards of Monitoring data. I strongly endorse the primary value of the vigilant An example of the need to be receptive to new infor­ anesthesiologist, but I conclude it is equally important, as mation and technology is the rapid acceptance of pulse recently emphasized by Tinker et al, to embrace proven oximetry as a standard of patient monitoring in the peri­ and practical monitors that enhance this vigilance.361 be­ operative period. As a personal bias, I believe that the lieve that pulse oximetry and capnography are examples acceptance of capnography is not far behind. There is an of such monitoring which, when properly used, improve old adage that there is nothing more compelling than an anesthesia care, as suggested by a reduction in the occur­ idea whose time has come. rence of preventable anesthetic mishaps. There are some who fear that increased reliance on monitors will distract the anesthesiologist and thus reduce Summary the level of personal or hands-on vigilance. Examples have been cited of time wasted checking instruments that were In conclusion, I hope that my comments have reaf­ presumed to be malfunctioning when in fact attention firmed your biases or, even more importantly, stimulated should have been directed to the patient.32 I believe, you to think in a different way about the information however, that these are infrequent and correctable errors explosion in our specialty and medicine in general. 1 be- Anesthesiology V74, No6,Junl CLINICAL CHALLENGES FOR THE ANESTHESIOLOGIST 1135

X MONITORS ^'VVVVV^#Mf%V ^^y^ Pulse Oximeter DD11IIDII FIG. 4. Pulse oximetry and capnography are frequently of some value in detecting mishaps that may occur in the anesthetized patient. The «*~I1IDDDII1II1DI value of the oxygen analyzer and electrocar­ diogram (ECG) in detecting these mishaps is limited. (Adapted with permission.35). -—'DDDDIDDDDDDDDD - DDDDDlDDDnDDID

HIGH MODERATE NO VALUE VALUE I|V2LTJE y VALUE

lieve our specialty is in a golden era that will benefit from 10. Martin JL, Kenna JG, Pohl LR: Antibody assays for the detection the past and be nourished by new discoveries and under­ of patients sensitized to halothane. Anesth Analg 70:154-159, standing. We as clinicians must accept the challenge of 1990 11. Slogoff S, Keats AS: Randomized trial of primary anesthetic agents recognizing what new information deserves incorporation on outcome of coronary artery bypass graft operations. ANES­ into our practice, what old information deserves to be THESIOLOGY 70:179-188, 1989 sustained, and what merits new scrutiny and perhaps 12. Slogoff S, Keats AS: Does chronic treatment with calcium entry should be discarded. blocking drugs reduce perioperative myocardial ischemia. If I had one wish, it would be that anesthesiologists ANESTHESIOLOGY 68:676-680, 1988 would never lose their zeal to be students—their thirst 13. Reiz S, Balfors E, Sorensen MB, Ariola S, Friedman A, Truedsson H: Isoflurane: A powerful coronary vasodilator in patients with for new information—as the continuum of anesthesia ed­ coronary artery disease. ANESTHESIOLOGY 59:91-97, 1983 ucation is indeed a life-long process. That wish, ladies and 14. Priebe H-J: Differential effects of isoflurane on regional right and gentlemen, is my challenge to all anesthesiologists. left ventricular performances, and on coronary systemic, and pulmonary hemodynamics in the dog. ANESTHESIOLOGY 66: References 262-272, 1987 15. Sill JC, Bove AA, Nugent M, Blaise GA, Dewey JD, Grabeau C: 1. Hershey SG: The Rovenstine inheritance: A chain of leadership. Effects of isoflurane on coronary arteries and coronary arterioles ANESTHESIOLOGY 59:453-458, 1983 in the intact dog. ANESTHESIOLOGY 66:273-279, 1987 2. Eger EI, Smuckler EA, Ferrell LD, Goldsmith CH, Johnson BH: 16. Buffington CW, Romson JL, Levine A, Duttlinger NC, Huang Is Enflurane hepatotoxic? Anesth Analg 65:21-30, 1986 AH: Isoflurane induces coronary steal in a canine model of 3. Summary of the national halothane study. JAMA 197:775-788, chronic coronary occlusion. ANESTHESIOLOGY 66:280-292, 1966 1987 4. Schemel WH: Unexpected hepatic dysfunction found by multiple 17. Priebe H-J, Foex P: Isoflurane causes regional myocardial dys­ laboratory screening. Anesth Analg 55:810-812, 1976 5. Wataneeyawech M, Kelly KA: Hepatic diseases unsuspected before function in dogs with critical coronary artery stenoses. ANES­ surgery. NY State J Med 75:1278-1281, 1975 THESIOLOGY 66:293-300,1987 6. Douglas HJ, Eger EI, Brava CG, Renzi C: Hepatic necrosis asso­ 18. Becker LC: Is Isoflurane dangerous for the patient with coronary ciated with viral infection after enflurane anesthesia. N Engl J artery disease? ANESTHESIOLOGY 66:259-261, 1987 Med 296:553-555, 1977 19. Hess W, Arnold B, Schulte-Sasse U, Tarnow J: Comparison of 7. Stoelting RK, Blitt CD, Cohen PJ, Merin RG: Hepatic dysfunction isoflurane and halothane when used to control intraoperative after isoflurane anesthesia. Anesth Analg 66:147-153, 1987 hypertension in patients undergoing coronary artery bypass 8. Hubbard AK, Roth TP, Gandolfi AJ, Brown BR, Webster NR, surgery. Anesth Analg 62:15-20, 1983 Nunn JF: Halothane hepatitis patients generate an antibody 20. Tarnow J, Markschies-Hornug A, Schulte-Sasse U: Isoflurane im­ response toward a covalently bound metabolite of halothane. proves the tolerance to pacing induced myocardial ischemia. ANESTHESIOLOGY 68:791-796, 1988 ANESTHESIOLOGY 64:147-156, 1986 9. Christ DD, Kenna JG, Kammerer W, Satoh H, Pohl LR: Enflurane 21. Buffington CW, Davis KB, Gillespie S, Pettinger M: The prevalence metabolism produces covalently bound liver adducts recognized of steal-prone coronary anatomy in patients with coronary artery by antibodies from patients with halothane hepatitis. ANES­ disease: An analysis of the coronary artery surgery registry. THESIOLOGY 69:833-888, 1988 ANESTHESIOLOGY 69:721-727, 1988 Anesthesiology 1136 ROBERT K. STOELTING V74, No6,Jun 1991

22. Priebe H-J: Isoflurane and coronary hemodynamics. ANESTHE­ 30. Basta SJ, AH HH, SavareseJJ, Sunder S, Gioiifriddo M, Cloutier SIOLOGY 71:960-976, 1989 G, Lineberry C, Cato AE: Clinical pharmacology of atracurium 23. Cote CJ: NPO after midnight for children: A reappraisal. ANES­ besylate (BW33A): A new non-depolarizing muscle relaxant. THESIOLOGY 72:589-592, 1990 Anesth Analg 61:723-729, 1982 24. Olsson GL, Hallen B, Hambraeus-Jonzon K: Aspiration during 31. Hunt R, Taveau RM: On the physiological action of certain cholin anaesthesia: A computer-aided study of 185,358 anaesthetics. derivatives and new methods for detecting cholin. Br Med J 2: Acta Anaesthesiol Scand 30:84-92, 1986 1788-1791, 1906 25. Tiret L, Nwoche Y, Hatton F, Desmonts JM, Vour'h G: Compli­ 32. Keats AS: Anesthesia mortality in perspective. Anesth Analg 71: cations related to anaesthesia in infants and children: A pro­ 113-119, 1990 spective survey of 40,240 anaesthetics. Br J Anaesth 61:263- 33. Comroe JB, Botelho S: The unreliability of cyanosis in the rec­ 269,1988 ognition of arterial anoxemia. Am J Med Sci 214:1-6, 1947 26. Roberts RB, Shirley MA: Reducing the risk of acid aspiration during cesarean section. Anesth Analg 53:859-868, 1974 34. Cote CJ, Goldstein EA, Cote MA, Hoaglin DC, Ryan JF: A single- 27. Raidoo DM, Rocke DA, Brock-Utne JG, Marszalek A, Engelbrecht blind study of pulse oximetry in children. ANESTHESIOLOGY HE: Critical volume for pulmonary acid aspiration: Reappraisal 68:184-188, 1988 in a primate model. Br J Anaesth 65:248-250, 1990 35. Whitcher C, Ream AK, Parsons D, Rubsamen D, Scott J, Cham- 28. Maltby JR, Sutherland AD, Sale JP, Shaffer EA: Preoperative oral peau M, Sterman W, Siegel L: Anesthetic mishaps and the cost fluids: Is a five hour fast justified prior to elective surgery? Anesth of monitoring: A proposed standard for monitoring equipment. Analg 65:1112-1116, 1986 J Clin Monk 4:5-15, 1988 29. McGrady EM, MacDonald AG: Effect of the preoperative admin­ 36. Tinker JH, Dull DL, Caplan RA, Ward RJ, Cheney FW: Role of istration of water on gastric volume and pH. Br J Anaesth 60: monitoring devices in prevention of anesthetic mishaps: A closed 803-805,1988 claims analysis. ANESTHESIOLOGY 71:541-546, 1989